Name (include the initials after your name)	Profiles listed alphabetically by last name.
Organization: Note: most individuals will leave this blank -- groups and treatment centers should click here.
Street Address	Your profile is categorized by this address. Have 2 offices? Just fill out one for now and put a note in the comments section at the end of this form and we will contact you.
Address (cont.)	This information will be listed on our site.
City
State/Province	2 digit code for your state in the US.
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
(Please include for our contact. See below for option to have it listed on web) Email
URL=Web Page (if applicable and you want it listed):	Please also place a link to our website on yours (it helps both our sites in the search engines).

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

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

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

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

Yes
No

What is your license type and number (if applicable)?

  If you are not licensed or registered, it will be noted in your profile.

What is your license expiration date (if applicable)?

What year did you begin treating eating disorders?

   (Required input)

Use the following space to include a single paragraph about your 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.

Example: I believe that each client is unique and requires an individualized treatment plan. Clients are partners in the recovery process and I engage them as such. I use self-psychology, cognitive-behavioral therapy and psychodynamic therapy primarily, but I also provide some nutrition counseling when warranted.  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:

Individual Therapy/Private Practice
Nutritional Counseling
Medical Evaluation
Day Treatment
College/University Counseling Program
Residential Treatment
Intensive Outpatient Program
Inpatient
Coaching
EMDR
Holistic Healing
Hypnosis
Biofeedback
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
PayPal
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?

Have you ever been named as a defendant in a malpractice action in the past five years or are there currently any professional liability complaints pending against you? (YES or NO). If yes, explain in full on a separate sheet and fax or mail the details to us.

NO
YES--If Yes, be sure to read the above paragraph carefully.

Have you ever been denied membership or a renewal thereof, or been subject to disciplinary proceedings by any local, state or national professional society? ( YES or NO). If yes, explain in full on a separate sheet and fax or mail the details to us.

NO
YES--If Yes, be sure to read the above paragraph carefully.

Do you swear that all of the information is true and correct to the best of your knowledge? AND do you agree to the following...I understand that my membership with EDReferral is dependent upon my continued status with my certification and or licensing bodies. I agree that if my state board license/registration/certification is revoked, suspended or expired, I will contact EDReferral and provide written documentation as to the reasons.

YES to the above
NO

NOTE: IF YOU DID NOT ANSWER ALL OF THE LAST 3 QUESTIONS, WE WILL HAVE TO CONTACT YOU BEFORE WE CAN PROCEED

Do you have anything you would like to add to your application? (If you add some information about yourself or your mode of therapy, it helps to personalize your listing.)  This must be a SINGLE paragraph.

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