EDRC Provider Listing Request
Thank you for your interest in being added to our resource directory. Please note that we only list providers located within the Bay Area, located in Northern California. Please complete all of the required fields marked with a red asterisk and note that any information you enter on this form will appear on our website.

After you submit this request, someone from our team will review your form and contact you to confirm your listing details. Please send an email to info@edrcsv.org or call us at (408) 356-1212 with any questions.
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Name *
Organization/Company Name *
Business Address *
Additional Business Address (if applicable)
Business Phone Number *
Additional Business Number (if applicable)
Business Email *
Additional Business Email (if applicable)
Business Website Address (if applicable) *
What kind of treatment professional are you? *
What are your CREDENTIALS/DISCIPLINE? *
Are you Board Certified? *
If you are board certified, what board?
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. *
Briefly describe your TREATMENT PHILOSOPHY. *
Languages *
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
Fees *
Required
Please list which insurance carriers you accept, or indicate N/A if none *
Are you an out-of-network provider? *
Do you provide Superbills? *
Please add any additional notes here (attachments, extra information for a section, etc.)
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