Delay the Binge Program Application Form

Welcome! I’m so glad you’re here.

Delay the Binge™ is more than a program.

It’s a transformational experience designed to help you interrupt the habits that hurt, and finally feel at peace in your body, your mind, and your life.

If you’ve ever found yourself stuck in cycles of emotional eating, overworking, people-pleasing, or unhealthy patterns that seem impossible to break… you’re not alone. And you’re not broken.

This program will help you:

Understand what’s really driving the binge (hint: it’s not food)

Rebuild trust with yourself one delay at a time

Learn tools to pause the cycle, shift your response, and choose what actually serves you

Replace shame with self-compassion
Build a new story rooted in purpose, not pain

Together, we’ll walk through the Delay the Binge™ Blueprint, a research-backed, lived-experience approach built on five simple but powerful steps.

Who this is for:

You’re ready to be honest about what’s really going on.

You’re committed to showing up for yourself, even if you’re scared or unsure.

You’re looking for more than a quick fix, you want sustainable change.

You’re ready to take back your power!

How to apply:

Please take a few minutes to answer the questions honestly. This helps me understand where you are, what you’re struggling with, and how I can support you best.

Once your application is reviewed, you’ll receive a follow-up email with next steps — including program details, pricing, and available start dates.

If you’re ready to finally break the cycle and remember who you are underneath the habit…

This is your moment.

Let’s Delay the Binge™, one choice at a time!

Pam Dwyer

Speaker | Author | Founder of Delay the Binge™

Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

What habit or pattern are you currently struggling with?

How does this pattern make you feel, emotionally, physically, or mentally?

Why do you feel now is the right time to work on it?

Are you willing to be recorded via Zoom and have your session used in public Delay the Binge™ content?

Yes, I give permission to be recorded and understand my session may be used.No, I’m not comfortable with that.

Do you agree to sign a media release form before the session?

YESNO

Anything else you’d like me to know?

Delay the Binge Coaching Session