About You and Your Services
Degree / Credentials
Which category best describes you? *
Therapist
Dietitian/Nutritionist
Psychiatrist
Physician
Yoga Professional
Expressive Arts
Business Name (if different from your name)
Business Address (please include street, city, state, zip) *
Business Phone *
Business Email
Business Website
What is your cost per session? *
Which payment options do you accept? Select all that apply. *
Credit cards
Insurance
Sliding scale
What insurance do you accept? *
Which populations do you treat? Select all that apply. *
Men
Women
Children
Teenagers/Adolescents
Adults
Older Adults
BIPOC
LGBTQ+
People with Disabilities
People in Larger Bodies
What are your specializations? Select all that apply.
Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder
Body Dysmorphic Disorder
ARFID
OSFED
OCD
PTSD
Addiction/Substance Use Disorder
What is your treatment approach? Select all that apply.
Cognitive Behavioral Therapy (CBT)
Dialectical Behavioral Therapy (DBT)
Eye Movement Desensitization and Reprocessing (EMDR)
Individual Therapy
Group Therapy
Couples Therapy
Family Therapy
Exposure Therapy
Experiential Therapy
Do you offer services in any languages other than English? If so, please specify. *
Are you available for free assessments? *
Yes
No
Are you interested in starting an ANAD affiliated support group? *
Yes
No
Are you interested in applying for ANAD’s Inclusive Care Seal of Approval? *
Yes
No
Please provide a short biography about yourself, your practice, and your treatment approach. This will be included in your listing in ANAD’s treatment directory. *
Please note: if you answer “yes” to any of the following questions, we will follow up with you by phone.
Have you ever been denied membership or been disciplined by any professional society? *
Yes
No
Have you ever been involved in a malpractice action? *
Yes
No
Do you have any professional liability complaints pending against you? *
If you answered “yes” to any of the questions above, please provide an explanation below.
Please type your full name and today's date below as your signature, indicating that all information provided above is accurate and truthful. *