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:
My Products
*
prev
next
( X )
Small Group Coaching Program
$1,997.00
$
1,997.00
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
Expiration Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Year
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
Should be Empty: