Application: Eating Healthy and Living Well at College Program

If you are interested in joining our next Eating Healthy and Living Well at College group, please fill out the application form below and Anita will be in touch with you to discuss if the group is a fit for you.

Please note:

We limit these groups to a maximum of 6 participants to ensure everyone receives the covid precautions, an equal opportunity to share experiences and receive the adequate support they need to learn these new skills.

Our Group programs are not covered by insurance.

Program details:

MEETING TIMES: Tuesdays from 6:00-7:15 pm
DATES: February 7, February 14, February 21, February 28, March 14, March 21, March 28
LOCATION: Virtually via Zoom
FEE: $395 or 2 payments of $215

Application for Eating Healthy and Living Well at College

Name(Required)

First Last

Phone(Required)

Email(Required)

Age(Required)

NOTE: This program is for participants between 18 and 23 (If you are outside this age group and looking for support, add a note in the comment below, and Anita will get back to you to discuss options.)

Are you currently enrolled in college YES or NO. If yes, which one?

Are you working with a provider or in treatment? - yes or no only

What are you hoping to get from joining this group?(Required)

Please share any information or history about yourself that I should know so that I can ensure you have the best experience possible in the group.

Are you paying for someone else? If yes, please fill out their name and email below.

Parent / Guardian Name(Required)

First Last

Parent or Guardian Phone Number(Required)