Not Your (Mother's) Diet

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July 2021 Group Application

Hello! I'm very excited that you are taking the first steps to healing your relationship with your body & food by joining this group. I use this application process to make sure you are getting exactly what you are looking for and that you will be placed in a group of other womxn who have similar needs.

Once you have been approved to join our July 2021 group, I will send you a calendar invite to schedule a pre-group 1:1introduction call with me as well as instructions for payment.

Talk soon!
xo Cassandra

Name

Phone Number

Date of Birth

YYYY

What are you looking to gain from being in this group?

On a scale of 1-10 rate how comfortable you are in your body, generally?

Very uncomfortable

Very comfortable

Clear selection

How often are you on a diet of any kind (restricting food for an ultimate goal).

Never

Sometimes (once every few months)

Often (once a month)

Always (most days)

Clear selection

Do you have health conditions that require you to be on a specialized diet (diabetes, kidney disease, etc)?

Yes

Clear selection

Are you in recovery from an eating disorder?

Yes

I am still active in an eating disorder.

Clear selection

Are you currently seeing a mental health provider?

Yes

Other:

Clear selection

What else would you like me to know about you?

Submit

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