EDRC Provider Listing Request
Please complete the following questions to be included in our local resource directory for the south bay and surrounding areas.
Name *
Your answer
Company *
Your answer
Address *
Your answer
Office Phone Number *
Your answer
Fax Number
Your answer
Public E-mail
Your answer
Website Address *
Your answer
What kind of treatment professional are you? *
What are your CREDENTIALS/DISCIPLINE? *
Your answer
Are you Board Certified? *
If you are board certified, what board?
Your answer
Do you prefer patients to contact you by phone or email? *
Is your office wheelchair accessible? *
How many years have you been treating patients with eating disorders? *
How many non-duplicated patients with eating disorders do you treat annually? *
Briefly describe your EDUCATION, TRAINING, and EXPERTISE. *
Your answer
Briefly describe your TREATMENT PHILOSOPHY. *
Your answer
Languages *
Your answer
Populations Served (Please check all that apply) *
Required
Conditions Treated (Please check all that apply) *
Required
Treatment Approaches (Please check all that apply) *
Required
Treatment Settings (Please check all that apply) *
Required
If you work at an outpatient location, are you willing and/or experienced in working as part of a team? *
Fees
If you are covered by "provider out of the network" in a PPO, do you require the patient to apply for reimbursement to their insurance provider or will you bill the patient's insurance provider? *
Do you think it is possible to recover from an eating disorder? *
If yes, how would you define recovery? *
Your answer
Please let us know of any other Eating Disorder Professionals who would like to be contacted and included in this directory (include name, phone number, and email)
Your answer
Please list any suggestions for improving our service or this form.
Your answer
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