About you and your services:
Degree / Credentials
Certificate and Year
Which category best describes you? *
Therapist
Dietitian/Nutritionist
Physician
Dentist
Yoga Professional
Psychiatrist
Expressive Arts
Business Name
Business Address (Please include street, city, state, zip) *
Business Phone *
Business Email
Business Website
What is your cost per session? *
Payment options you accept *
Credit Cards
Insurance
Sliding Scale
What insurance do you accept? *
Populations you treat *
Women
Men
Adolescents
Elderly
Athletes
Specialization
Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder
Body Dysmorphic Disorder
Obesity
Nutrition
Self Injury
OCD
Drug/Alcohol Addiction
Compulsive Exercise
Treatment Approach
Individual Therapy
Group Therapy
Couples Therapy
Family Therapy
Language fluency besides English: *
Are you available for free assessments?
Yes
No
Please provide a short biography about yourself, your practice, and your treatment approach for helping clients with eating disorder recovery. This will be included with your listing in ANAD's Treatment Database. *
*PLEASE NOTE: If you answer YES to any of the following 3 questions, we will follow up 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? *
If you answered YES to any of the last three questions, please explain below.
Other ANAD Services:
Are you interested in assistance with starting an ANAD Support Group at your facility?
Yes
No
What two therapy topics could you provide expert opinions on for future ANAD blog posts and videos? (If not interested, please indicate) *
Please type your full name and today's date below as your signature, indicating that all information provided above is accurate and truthful. *