EBT Facilitator Training Application Form

Facilitator Training Application

Thank you for your interest in undertaking the Eat Breathe Thrive Facilitator Training.

Applicants are considered based on professional experience, facilitation skills, community involvement, and leadership abilities.

To be considered for admission, you must:
- Complete the Eat Breathe Thrive Immersion.
- Be a helping professional.
*

I have reviewed and can confirm that I meet the admission criteria detailed above.
About You

Personal Information
Your Name:*

First NameLast Name
E-mail:
Date of birth:

MonthDayYear
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Please upload a headshot:

Browse Files
We like to put a name to a face... plus, it helps us to remember who you are! Cancelof
Co-Facilitation
Should you choose to co-facilitate, your application will be considered in conjunction with your co-facilitator's. Do you wish to add a co-facilitator?

YesNo
Co-Facilitator's Name:

First NameLast Name
Co-Facilitator's Email:
example@example.com
Inclusivity Matters

The following section informs our efforts in ensuring diversity and inclusivity. Any information you provide may be stored and used in accordance with our Privacy Policy. For the purpose of confidentiality, any identifying information will be removed or changed before data is used in any way.
Age:*
Ethnicity:*

Non-Hispanic White or Euro-AmericanBlack, Afro-Caribbean, African American, or African EuropeanLatino, Hispanic American, or Hispanic EuropeanEast Asian, Asian American, or Asian EuropeanSouth Asian, Indian American, or Indian EuropeanMiddle Eastern, Arab American, or Arab EuropeanNative American or Alaskan NativeI'd prefer not to sayOther
Please specify your gender identity:*

Cis womanCis manTrans womanTrans manNon-binaryGenderqueerGender fluidAgenderI'd prefer not to sayOther
Please specify your sexual orientation:*

StraightGayLesbianBisexualAsexualQueerI’d prefer not to sayOther
What is your household income?

Less than $15,000/year$15,000–$30,000/year$30,000–$50,000/year$50,000–$75,000/year$75,000–$100,000/yearOver $100,000/yearI’d prefer not to say
What is your household income?

Less than £15,000/year£15,000–£30,000/year£30,000–£50,000/year£50,000–£75,000/year£75,000–£100,000/yearOver £100,000/yearI’d prefer not to say
What is your household income?

Less than €15,000/year€15,000–€30,000/year€30,000–€50,000/year€50,000–€75,000/year€75,000–€100,000/yearOver €100,000/yearI’d prefer not to say
Skills and Experience

Eat Breathe Thrive Participation
Have you previously taken an Eat Breathe Thrive training, course, or program?*

YesNo
Which of the following have you participated in? Please check all that apply.

Eat Breathe Thrive Immersion (In-Person)Eat Breathe Thrive Online ImmersionEating Disorders: How Yoga Teachers Can HelpEat Breathe Thrive Seven-Week SeriesYoga for Eating Disorder Recovery: A Four-Week Online Course
When did you take the Eat Breathe Thrive Immersion?
Don't worry if you can't remember the exact dates! Just the month and year will suffice.
When did you complete Eating Disorders: How Yoga Teachers Can Help?
In which month and year did you participate in the Eat Breathe Thrive series?
In which month and year did you participate in Yoga for Eating Disorder Recovery?
Your Professional Experience
Do you work in any of the following professional fields?
Mental Healthcare*

YesNo
Medical Healthcare*

YesNo
Complementary Healthcare*

YesNo
Education*

YesNo
For how long have you been working in mental healthcare?
In which mental healthcare profession(s) are you qualified?
e.g. Psychologist, Psychiatrist, Therapist, Social worker, Counselor
For how long have you been working in medical healthcare?
In which medical healthcare profession(s) are you qualified?
e.g. Doctor, Nurse, Nutritionist, Dietitian, Occupational therapist, Physical therapist
For how long have you been working in complementary healthcare?
In which complementary healthcare profession(s) are you qualified?
e.g. Yoga teacher, Massage therapist, Chiropractor, Acupuncturist, Naturopathic doctor, Life coach
For how long have you been working in education?
In which educational profession(s) are you qualified?
e.g. Teacher, Faculty, Coach, School counselor, Parent
What is your educational and/or training background?
Skillsets
Consider the following skills and rate yourself on a scale of 1-5, where 1 is poor, and 5 is excellent:

Time Management Skills*

	1	2	3	4	5

1 is Poor, 5 is Excellent

Communication Skills*

	1	2	3	4	5

1 is Poor, 5 is Excellent

Listening Skills*

	1	2	3	4	5

1 is Poor, 5 is Excellent

Problem Solving Skills*

	1	2	3	4	5

1 is Poor, 5 is Excellent

Marketing Skills*

	1	2	3	4	5

1 is Poor, 5 is Excellent

Do you have previous experience of using MINDBODY online software?*

YesNo
Group Facilitation Experience
Do you have any experience in group facilitation?*

YesNo
Please give details of your experience in group facilitation, below:
Supporting Documents
Please upload your resume.*

Upload a File

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Please upload a current copy of your professional insurance.*

Upload a File
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Your Healing Journey
Do you have personal experience of food and/or body image issues?*

YesNo
What has your journey of healing from food and body image issues entailed?
Have you ever been diagnosed with an eating disorder?*

YesNo
For each of the following levels of care, please indicate when you last received treatment (if not applicable, please select "never").
Inpatient
Day Patient
Intensive Outpatient (IOP)
Outpatient
Introspection

Traits
Consider the following traits and rate yourself on a scale of 1-5, where 1 is not at all, and 5 is extremely:

Confident*

	1	2	3	4	5