Participant Application Form

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Yoga For Eating Disorder Recovery

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.
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Name
First Name
Last Name
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Phone Number
Area Code
Phone Number
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Email
example@example.com
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Date of birth:* This field is required.
Please note, you must be 16+
Month
Day
Year
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Address:* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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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.
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Do you currently have an eating disorder?* This field is required.
Yes
No
I'm not sure
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Please indicate which option best describes your current eating disorder. Please tick all that apply.* This field is required.
Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder
ARFID (Avoidant / Restrictive Food Intake Disorder)
EDNOS / OSFED
Other
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Are you currently receiving treatment or professional support for an eating disorder?* This field is required.
Yes
No
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Please select any that apply:
Individual therapy or counselling
Dietitian or nutrition support
Outpatient eating disorder support
Intensive outpatient
Day treatment
Residential treatment
Inpatient treatment
Other (please describe)
Other
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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)?
Yes
No
Not sure
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In the past month, have you experienced any of the following?* This field is required.
You have had a heart rate that is consistently very low, episodes of dizziness or fainting, or signs of dehydration or electrolyte problems
You have needed hospital or urgent medical care related to eating, weight loss, or nutrition
You have experienced rapid or significant weight loss (i.e., at a rate of more than 2lbs or 1kg per week, or more than 5 percent of your body weight in a month)
Your BMI has been below 16
None of the above
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In the past three months, have you had thoughts about wanting to harm yourself or not wanting to be alive?
Yes
No
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In the past month, have you tried to harm yourself or take your own life?
Yes
No
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Do you currently have a therapist or other mental health professional you can contact if you start to feel unsafe or overwhelmed?
Yes
No
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In the past month, have you engaged in any of the following behaviours?
Physically harming yourself, such as cutting, scratching, burning, or hitting yourself
Making preparations to harm yourself or researching ways to do so
None of the above
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Agreements

Please keep a copy of the agreements linked below for your records.
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Terms and Conditions* This field is required.
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Terms and Conditions* This field is required.
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Terms and Conditions* This field is required.
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Terms and Conditions* This field is required.
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Terms and Conditions* This field is required.
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Signature:* This field is required.Please type out name
First Name
Last Name
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Signature:* This field is required.
Clear
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Can you please confirm if you are 18 or older?Participants under 18 will need a parent or guardian signature.
YESNO
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Parent/Guardian Name:*if ages 16 -17
First Name
Last Name
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Parent/Guardian Signature:
Clear
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Date:
Month
Day
Year
Should be Empty:

Yoga For Eating Disorder Recovery

Participant Application

Your Health and Wellbeing

Agreements