Eat Move Meditate Application
Thank you so much for your interest in the Eat Move Meditate program. We're so excited that you're interested and we can't wait to learn more about you. Please fill out this form to ensure that we are a good fit and we will be in touch soon.

If you don't want to provide this information in the application, we would be happy to have a Zoom call with you instead -- just fill in your contact information and select 'Zoom call, please' in question four.

All answers are confidential.
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Name *
Email *
Phone Number *
Would you like to continue with the online application or do this over a Zoom call instead? If you would rather the zoom, please hit submit on the form now (you don't have to answer the rest) and one of us will be in touch with you. *
What payment option will you prefer? *
Were you referred by anyone? If so, who? *
What is your main intention for participating in this course? *
List three personal goals you have as you enter this course. *
How would you describe your fitness level?  All levels are welcome! *
If you wish to help the instructors know more about you please write a few sentences about yourself such as the things you love, the things that give you pleasure in life, the things you are most concerned about or anything else you wish.
Do you have a history of substance abuse that may affect your ability to participate in and complete this course? If so consult with those who support your recovery to assure you that this course is appropriate for you at this time. *
Do you have a history disordered eating that may affect your ability to participate in and complete this course?  If so consult with those who support your recovery to assure you that this course is appropriate for you at this time. *
Are you currently in psychotherapy for a condition that may affect your ability to participate in and complete this course? If so discuss your participation in this course with them to assure you that this course is appropriate for you at this time. *
Are you under medical care for any medical condition, physical injuries,  or taking medications that affect your ability to participate in and complete this course? If so consult with your doctor about your participation in this course to assure you that this course is appraise for you at this time. *
Do you have any other questions or comments for us?
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