In Dev - Participant Application Form

7 Week Series

Participant Application

Thank you for your interest in taking an Eat Breathe Thrive course.

Eat Breathe Thrive courses are a supportive group experience and not a substitute for medical or psychological treatment. They are intended for individuals who are stable enough to participate in mindful movement and discussion in a group setting. The course may not be suitable if you are currently struggling with self-harm or suicidal thoughts. If you are in recovery from an eating disorder, we recommend waiting until you are in a stable place in your recovery to participate.

Please read the following questions carefully. The entire application process should take no more than 5 minutes.
About You

Personal Information
Name:*

First NameLast Name
Phone Number:*
Email:*
example@example.com
Date of birth:*

MonthDayYear
Please note, you must be 16+
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Which course are you applying for?*

Jan 14 - Feb 26 with Federica LodoJan 11 - Feb 22 with Laura Jaramillo & Maggie Milone
How did you hear about the course?*

Eat Breathe Thrive newsletterEat Breathe Thrive FacilitatorFacebookInstagramTwitterLinkedInOther social mediaFriend or loved oneReferred by professionalReferred by organizationInternet searchwww.eatbreathethrive.orgwww.givebackyoga.orgOnline event listingPrinted flyer or postcardNewspaper/magazine adOther
Please select all of the following that apply to you:*

Yoga professionalMental health professionalHealthcare professionalEducatorNutritionist / DieticianResearcherPeer MentorRecovery CoachCaregiverIn recovery from an eating disorderIn recovery from disordered eatingIn recovery from body image disturbancesRecovered or in sustained long-term recoveryNone of the above
Your Health and Wellbeing

The next few questions ask about emotional wellbeing and safety. We ask these of everyone applying to the course. Your answers help us understand whether this group is the right level of support and to connect you with other resources if needed.
Do you currently have an eating disorder?*

YesNoI'm not sure
Please indicate which option best describes your current eating disorder. Please tick all that apply.*

Anorexia NervosaBulimia NervosaBinge Eating DisorderARFID (Avoidant / Restrictive Food Intake Disorder)EDNOS / OSFEDOther
Are you currently receiving treatment or professional support for an eating disorder?*

YesNo
Please select any that apply:

Individual therapy or counsellingDietitian or nutrition supportOutpatient eating disorder supportIntensive outpatientDay treatmentResidential treatmentInpatient treatmentOther (please describe)Other
Have you been advised to attend, or are you currently awaiting, a higher level of care for your eating disorder (such as day patient, residential, or inpatient treatment)?

YesNoNot sure
In the past month, have you engaged in any of the following?*

Purging, for example vomiting or misusing laxatives or diureticsRestricting food or fasting to the point of feeling dizzy, faint, or unwellUsed any supplements, medications, or other substances with the intention of changing your bodyNone of the above
In the past month, have you experienced any of the following?*

Needing medical monitoring because of low heart rate, low blood pressure, or electrolyte imbalanceHospitalization or urgent medical care related to eating or nutritionBeing told that your weight is below a healthy rangeNone of the above
In the past three months, have you had thoughts about wanting to harm yourself or not wanting to be alive?

YesNo
In the past month, have you tried to harm yourself or take your own life?

YesNo
Do you currently have a therapist or other mental health professional you can contact if you start to feel unsafe or overwhelmed?

YesNo
Agreements

Please keep a copy of the agreements linked below for your records.
Name:*

First NameLast Name
Signature:*

Clear
Parent/Guardian Name:

First NameLast Name
Parent/Guardian Signature:

Clear
Date:

MonthDayYear
Should be Empty:

7 Week Series

Participant Application

About You

Personal Information

Your Health and Wellbeing

Agreements