1. Resource Directory Application

IMPORTANT: At this time our survey is full and is not accepting any new responses. Please check back at a later time.

Please complete the following questions to be included in the first local resource directory for the south bay and surrounding areas.
* Denotes required information.

Question Title

* 1. Please complete the information below:

Question Title

* 2. What is your:

Question Title

* 3. What kind of treatment professional are you?

Question Title

* 4. What are your CREDENTIALS/DISCIPLINE? (max. 200 characters)

Question Title

* 5. Are you Board Certified? (max. 60 characters)

Question Title

* 6. Do you prefer patients to contact you by phone or e-mail?

Question Title

* 7. Is your office wheelchair accessible?

Question Title

* 8. How many years have you been treating patients with eating disorders?

Question Title

* 9. How many unduplicated patients with eating disorders do you treat annually?

Question Title

* 10. Briefly describe your EDUCATION, TRAINING, and EXPERTISE: (max. 240 characters)

Question Title

* 11. Briefly describe your TREATMENT PHILOSOPHY: (max. 240 characters)

Question Title

* 12. LANGUAGES: (max. 120 characters)

Question Title

* 13. POPULATIONS SERVED:
(Please check all that apply)

Question Title

* 14. CONDITIONS TREATED:
(Please check all that apply)

Question Title

* 15. TREATMENT APPROACHES:
(Please check all that apply)

Question Title

* 16. TREATMENT SETTINGS:
(Please check all that apply)

Question Title

* 17. If you work at an outpatient location, are you willing and/or experienced in working as part of a team?

Question Title

* 18. FEES:
(Please check all that apply)

Question Title

* 19. If you are covered by "Provider out of the network" in a PPO, do you require the patient apply for reimbursement to their insurance provider or will you bill the patient's insurance provider?

Question Title

* 20. Do you think it is possible to recover from an eating disorder?

Question Title

* 21. If yes, how would you define recovery? (max. 500 characters)

Question Title

* 22. Please let us know of any other Eating Disorder Professionals who would like to be contacted and included in this directory:

Question Title

* 23. Please list any suggestions for improving our service or this form: (max. 200 characters)

T