Facility Name	Listings are filed alphabetically.
Director or Contact Person
Person filling out this form (if different than above)
Street Address	The profile is categorized by this address
Address (cont.)
City
State/Province
Zip/Postal Code	(We do not list your zip code to discourage junk mailings.)
(if outside the US) Country
Office Phone
(will not be listed) FAX
See below for option to have it listed on web)Email
URL=Web Page :

Please also place a link to our web site on yours (it helps both our sites in the search engines).

List Additional Communities Served by Your Facility (Include any major college campuses) (max=7 cities/locations):

These locations are added to your profile to help attract more clients to your facility.  DO NOT INCLUDE THE CITY WHERE YOUR FACILITY IS LOCATED...THIS IS FOR ADDITIONAL LOCATIONS ONLY.

Do you want your email included with your listing on our site?

Yes
No

What year did your center begin treating eating disorders?

   (Required input)

Please describe the primary Treatment Model or Philosophy at your facility:

Use the following space to include a single paragraph about the program's Treatment Model/Philosophy.  The more you can personalize it, the better.  Look on our site for examples of what others have done with their listing.

Note: if you write it in the first person or as an endorsement, it will be listed in italics.

Treatment Settings and Approaches that apply:

Inpatient
Residential Treatment
Intensive Outpatient Program
Partial Hospitalization
Medical Evaluation
Day Treatment
College/University Counseling Program
Nutritional Counseling
Biofeedback
Coaching
EMDR
Holistic Healing
Hypnosis
Family Therapy
Couples Therapy
Group Therapy
Support Groups
Phone Counseling

Select any of the following populations served (check all that apply):

Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder
Obesity
Food Addiction
Compulsive Overeating
Men with Eating Disorders
Children with Eating Disorders
Adolescents with Eating Disorders
Infants with Eating Disorders
Athletes with Eating Disorders
Compulsive Exercisers
Bariatric Surgery Assistance
Obsessive Compulsive Disorder OCD
Body Dysmorphic Disorder BDD
Night Eating Syndrome
Laxative Abuse
Pica

Select any of the following payment options that apply (we assume you take cash and checks):

Sliding Scale
Insurance
Medicaid
Medicare
Credit Cards

List any specific insurance plans that you want included in your profile (optional)

How did you hear about us?--please be as specific as possible

Please list any suggestions for improving our service or this form.  Also, do you know any therapists who would like to be contacted about membership?

Will you be mailing a check or paying online?

Mailing a Check  to EDRIC at 2923 SANDY POINTE STE 6 DEL MAR CA 92014
Credit Card/PayPal Online -- payment page will appear when you click the SUBMIT FORM button below

Do you, as the person listed above, swear that all of the information is true and correct to the best of your knowledge?

YES
NO

NOTE: IF YOU DID NOT ANSWER THE LAST QUESTION, WE WILL HAVE TO CONTACT YOU BEFORE WE CAN PROCEED

Write a single paragraph about your facility to personalize your listing. Include any information about certifications or accreditations your facility has such as CARF, JCAHO, etc.   Look on our site for examples of what others have done with their listing.

WHEN YOU ARE FINISHED, CLICK THE "SUBMIT FORM" BUTTON BELOW