Rock Recovery Program Interest Form
Thank you for your interest in working with us! We offer affordable therapy groups and peer support services to to help you find freedom from disordered eating and live your life to the full. (For more information visit http://rockrecoveryed.org/programs.)

Our group and individual clinical programs/services are currently available to residents of Virginia, Maryland, Washington, DC and California. (To learn about our nationwide support and education services visit https://rockrecoveryed.org/community-education-services.)

You are worth recovery, and we would love to work with you on your journey to healing. If you are interested in learning more about joining our unique community, please fill out the form below. A member of our team will be in touch within one business day.

If you have any questions, please email us at freedom@rockrecoveryed.org or call us at 571-255-9906. Please note due to COVID-19 currently all programs/services are provided virtually.


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First and Last Name *
Email Address *
Phone Number *
May we leave a voice message if we don't reach you when we call? *
What is your zip code? *
What is your date of birth? *
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DD
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YYYY
How did you hear about us? *
Required
Are you currently receiving any treatment for your eating disorder (including working with a clinician or taking part in a program)? *
If yes, where? *
What services are you interested in learning more about? Check all that apply. (Please note ALL services are virtual until at least February 2021.) *
Required
What do you hope to accomplish in your own recovery by working with us?
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