The Village Provider Alliance Application
We are SO excited about your interest in The Village Provider Alliance! This application is to help ensure that we are accountable to the credibility and integrity of our specialties. Once your application is completed, we will reach out in 2-3 business days to discuss any further questions and logistics. 
Name and Credentials  *
Email *
To what extent have you worked with the perinatal population and eating disorders? What are the trainings or educational tools you have utilized regarding these subjects?
In what ways do you see yourself adding value to The Village Provider Alliance? What are your strengths and expertise? *
Who is your ideal client? Do you have a special area of interest?
What insurance companies are you in network with? Do you offer sliding scale or pro-bono care? What is your self pay rate? *
Where is your practice located? Do you offer telehealth?
Is there anything else you'd like us to know? 
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