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.

Please complete the information below:

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* 1. Please complete the information below:

What is your:

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* 2. What is your:

What kind of treatment professional are you?

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* 3. What kind of treatment professional are you?

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

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

Are you Board Certified? (max. 60 characters)

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

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

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

Is your office wheelchair accessible?

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* 7. Is your office wheelchair accessible?

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

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

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

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

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

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

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

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

LANGUAGES: (max. 120 characters)

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* 12. LANGUAGES: (max. 120 characters)

POPULATIONS SERVED:
(Please check all that apply)

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

CONDITIONS TREATED:
(Please check all that apply)

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

TREATMENT APPROACHES:
(Please check all that apply)

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

TREATMENT SETTINGS:
(Please check all that apply)

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

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

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

FEES:
(Please check all that apply)

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

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?

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* 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?

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

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

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

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

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

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

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

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

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