HEALers Circle Application

Thank you for your interest in joining the HEALers Circle. Please tell us about yourself.


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* 1. Contact Information

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* 2. Which level(s) of treatment can you offer as a member of the HEALers Circle?  Please check all that apply.

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* 3. Do you treat male clients/patients?

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* 4. Do you treat adolescents?

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* 5. Which of these marginalized identities do you or your staff represent?

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* 6. If you are an outpatient provider, please list your degree(s). If you are a residential or PHP provider, please write "n/a." 

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* 7. If you are an outpatient provider, please list any trainings, CEU, or certifications related to eating disorders. If you are a residential provider, please answer "N/A." 

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* 8. Which treatment modalities do you use in your facility or practice?

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* 9. The “treat to outcome” philosophy means that the provider uses their clinical expertise to step the patient down to lower levels of care, rather than letting insurance companies or other external forces make that determination. Can you commit to the "treat to outcome" philosophy when treating a Project HEAL grant recipient?

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* 10. What percent of your patients/clients are you treating for eating disorders?

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* 11. Do you practice a “health at every size” approach to eating disorder recovery?

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* 12. Do you speak any languages other than English? Please list.

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* 13. Which health insurances, if any, do you accept? When people call Project HEAL for referrals, we will refer them to you. If you do not accept insurance, please tell us here.

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* 14. Do you have any other areas of expertise, like PTSD/trauma, substance use disorders, etc.?

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* 15. In which states are you licensed to practice?

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* 16. Do you offer telephone or virtual sessions?

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* 17. Would you be willing to ask 3 to 5 providers in your professional network to join the HEALers Circle? 

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* 18. Members of the HEALers Circle can be featured in a video interview to promote your practice on Project HEAL's social media pages. Would you like to be in video? 

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* 19. Is there anything else you would like Project HEAL to know about you? 

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* 20. How did you hear about the HEALers Circle? Who referred you? We're so glad you found us! 

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