About You and Your Services
Degree / Credentials
Which category best describes you? *
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. *
What insurance do you accept? *
Which populations do you treat? Select all that apply. *
What are your specializations? Select all that apply.
What is your treatment approach? Select all that apply.
Do you offer services in any languages other than English? If so, please specify. *
Are you available for free assessments? *
Are you interested in starting an ANAD affiliated support group? *
Are you interested in applying for ANAD’s Inclusive Care Seal of Approval? *
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? *
Have you ever been involved in a malpractice action? *
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. *
