Small Group Coaching Application
January 4th through March 1st, 2023
Name
*
First Name
Last Name
Email
*
example@example.com
Select your Timezone
*
Are you able to attend at least 6 of the 7 sessions listed here?
*
Yes
No
Wednesday, January 4th, 2023, 12pm–1pm PT
Wednesday, January 18th, 2023, 12pm–1:30pm PT
Wednesday, January 25th, 2023, 12pm–1:30pm PT
Wednesday, February 1st, 2023, 12pm–1:30pm PT
Wednesday, February 8th, 2023, 12pm–1:30pm PT
Wednesday, February 15th, 2023, 12pm–1:30pm PT
Wednesday, March 1st, 2023, 12pm–1:30pm PT
Are you able to commit to setting aside 30 minutes per day for assigned practices and exploration for this Program (between January 18th and March 1st)?
*
Yes
No
Briefly share why you want to participate in this Program. What are you struggling with? What do you hope to achieve?
*
I understand that the intention of this program is to heal my relationship with food, and is not about weight loss.
*
Yes
No
Do you currently have a mindfulness meditation practice? If so, briefly explain what this looks like.
*
Are you currently diagnosed with Anorexia or Bulimia?
*
Yes
No
Are you currently diagnosed with Binge Eating Disorder (BED)?
*
Yes
No
If you are diagnosed with BED, do you have a mental health professional or therapist available for support?
*
Yes
No
I am not currently diagnosed with BED
If there are any additional comments or notes you’d like Alyssia to be aware of, please share them here:
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Small Group Coaching Program
$
1,997.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please note
Your credit card will only be charged if your application is approved. A decision will be made about your application within 24 hours of submission. If your application is not approved, your card will NOT be charged.
Your information is 100% secure and will never be shared with anyone ever.
I understand that if my application is approved, my card will be charged the full amount noted above and that no refunds are offered once the program begins.
*
I understand
Submit Application
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