Is your facility applying for a new membership or are you updating your current listing? (This page can  be used to update your profile. You do not need to complete the entire form again. You can update your listing at any time by including your name, your state, and any information you want to change--another option is to email your listing to us at EDReferral.com with your changes.)

New (please only fill this out if you are serious about completing the application)
Update (at minimum, please include your company name, city and state)

Facility Name
Director or Contact Person
Person filling out this form (if different than above)
Street 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):

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

Yes
No

What year did your center begin treating eating disorders?

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

Examples: Cognitive Behavioral, Psychodynamic, Self-Psychology, Psychopharmacology, Feminist Approach, Eclectic, Non-Diet Approach, Dance Therapy, Nutrition Counseling  --or a combination

Treatment Settings and Approaches that apply:

Inpatient
Residential Treatment
Outpatient
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
Obsessive Compulsive Disorder OCD
Body Dysmorphic Disorder BDD
Night Eating Syndrome
Pica

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

Sliding Scale
Insurance
Medicaid
Medicare
Credit Cards

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 paying by mailing a check, paying by PayPal, or faxing credit card info?

Mailing a Check  to EDRIC at 2923 SANDY POINTE STE 6 DEL MAR CA 92014
PayPal -- see below for link to use PayPal
Faxing Credit card Information to our private fax (the next web page has the details)

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 paragraph or two about your facility to personalize your listing. Include any information about certifications or accreditations your facility has such as CARF, JCAHO, etc.

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