Eating Disorder Coach Program Application
* Required
Name
*
Your answer
PROGRAM COST $4850
**A payment plan is available. More details are provided in the student contract and on the "FAQ" on the website.
Date of Birth
*
MM
/
DD
/
YYYY
Address (Number and street name)
*
Your answer
Address (City, State, Zip Code and Country)
*
Your answer
Email Address
*
Your answer
Phone Number (Home)
*
Your answer
Additional Phone Number (Cell, work, etc.)
Your answer
Gender
*
Female
Male
Prefer not to say
Other:
Profession (Include any professional licenses or certificates)
*
Your answer
Current Employer
*
Your answer
Check All of the Following Avenue(s) of Eating Disorder Coaching You Are Interested In:
*
I want to open my own eating disorder coaching service/business
I want to enhance my current coaching business to expand into eating disorders
I am a clinician and want to obtain additional training to better serve my clients
I am already in a service career (yoga teacher, personal trainer, educator, etc.) and want to best help my eating disorder clients
I currently work for a coaching business and want/need to get certified
I want to work for an existing coaching business after I am certified
Other:
Required
Are you currently involved with any eating disorder organizations? This includes volunteers.
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Yes
No
**If yes to the question above, please list the organization(s) you are involved with, for how long and your role(s).
Your answer
Have you been trained as a Carolyn Costin Eating Disorder Mentor?
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Yes
No
**If yes to the question above, please answer ALL of the following: (1) Name of organization (2) Date of mentor diploma (3) Dates served as a mentor (4) Please briefly describe your experience:
Your answer
How did you hear about The Carolyn Costin Institute?
*
Social Media (Facebook, Twitter, etc.)
Carolyn’s website
Carolyn’s lecture/workshop
Received a flyer/mailing
Online search
Friend/referral
Coaching organization
Other:
Required
**If you can provide more specific details about your answer above, we would love to know (i.e. which social media site you saw us on, who specifically referred you, etc.)
Your answer
Highest Level of Education Completed: If you did not receive a Bachelor's degree or above, you must answer the following question (request for Bachelor's degree waiver)
*
**High School Diploma or Equivalent (waiver required)
**Some College (waiver required)
**Associate’s Degree/Two-Year Technical Degree/Vocational School (waiver required)
Bachelor’s Degree
Graduate or Professional Degree
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