Name (include the initials after your name)
Organization: Note: most individuals will leave this blank
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
(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 web site on yours (it helps both our sites in the search engines).

(REMINDER: If you are a NEW MEMBER, then click here to fill out the new member application.)

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 year did you begin treating eating disorders?

 Use the following space to update your 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 listings. 

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

Treatment Settings and Approaches that you want to add to your listing:

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

Select any of the following populations that you want to add to your listing:

Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder
Obesity
Food Addiction
Bariatric Surgery Assistance
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 you want to add to your listing (we assume you take cash and checks):

Sliding Scale
Insurance
Medicaid
Medicare
Credit Cards

List any information you want to REMOVE from your profile (nothing will be removed unless you ask for it specifically):

Do you have anything else you would like to ADD to your listing? (Adding information about yourself or your mode of therapy is important to personalize your listing.) This must be a SINGLE paragraph.  You can also include any note to the person updating your information.  If you DID NOT input your email address above, you could let us know which email address is best to send a confirmation receipt.

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