First and Last Name

Credentials

Business Name

Website

Select All that Apply Select All that Apply Treatment Facility Dietitian Therapist Psychiatrist Psychologist Medical Doctor Group Therapy Other

Street Address

Street Address #2

City

State

Zip

Describe your practice and experience in 300 words or less

PLEASE READ AND COMPLETE PLEASE READ AND COMPLETE I attest that the information submitted is true and accurate and that I am qualified to work with those seeking treatment for an eating disorder.