Are you applying for a new membership or are you updating your current listing? (This page can  be used to update your profile. You do not need to complete the entire form again. You can update your listing at any time by including your name, your state, and any information you want to change.)

New (please only fill this out if you are serious about completing the application)
Update (at minimum, please include your full name or company name, city and state)

Name (include the initials after your name)
Organization: Note: most individuals will leave this blank -- groups and treatment centers should click here.
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code	(We do not list your zip code to discourage junk mailings.)
(if outside the US) Country
Office Phone
(will not be listed) FAX
(Please include for our contact. See below for option to have it listed on web) Email
URL=Web Page (if applicable and you want it listed):	Please also place a link to our web site on yours (it helps both our sites in the search engines).

Please also place a link to our web site on yours (it helps both our sites in the search engines).

List Additional Communities Served by Your Office (Include any major college campuses) (max=7 cities/locations):

Do you want your email included with your listing on our site?

Yes
No

What is your license type and number (if applicable)?

  If you are not licensed or registered, it will be noted in your profile.

What is your license expiration date (if applicable)?

What year did you begin treating eating disorders?

Please include a paragraph about your Treatment Model/Philosophy:

Examples: Cognitive Behavioral, Psychodynamic, Self-Psychology, Psychopharmacology, Feminist Approach, Eclectic, Non-Diet Approach, Dance Therapy, Nutrition Counseling  --or a combination

Treatment Settings and Approaches that apply:

Individual Therapy/Private Practice
Nutritional Counseling
Medical Evaluation
Day Treatment
College/University Counseling Program
Residential Treatment
Outpatient
Inpatient
Coaching
EMDR
Holistic Healing
Hypnosis
Biofeedback
Family Therapy
Couples Therapy
Group Therapy
Support Groups
Phone Counseling

Select any of the following populations served (check all that apply):

Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder
Obesity
Food Addiction
Compulsive Overeating
Men with Eating Disorders
Children with Eating Disorders
Adolescents with Eating Disorders
Infants with Eating Disorders
Athletes with Eating Disorders
Compulsive Exercisers
Obsessive Compulsive Disorder OCD
Body Dysmorphic Disorder BDD
Night Eating Syndrome
Pica

Select any of the following payment options that apply (we assume you take cash and checks):

Sliding Scale
Insurance
Medicaid
Medicare
Credit Cards

How did you hear about us?--please be as specific as possible

Please list any suggestions for improving our service or this form.  Also, do you know any therapists who would like to be contacted about membership?

Have you ever been named as a defendant in a malpractice action in the past five years or are there currently any professional liability complaints pending against you? (YES or NO). If yes, explain in full on a separate sheet and fax or mail the details to us.

NO
YES--If Yes, be sure to read the above paragraph carefully.

Have you ever been denied membership or a renewal thereof, or been subject to disciplinary proceedings by any local, state or national professional society? ( YES or NO). If yes, explain in full on a separate sheet and fax or mail the details to us.

NO
YES--If Yes, be sure to read the above paragraph carefully.

How will you pay your membership dues? (Either way, you still need to mail or fax a copy of your license and insurance--if applicable.)

Mailing a Check    to EDRIC at 2923 SANDY POINTE STE 6 DEL MAR CA 92014
Credit Card/PayPal Online -- see below for link to pay online
Faxing Credit card Information to the private fax (the next web page has the details)

Do you swear that all of the information is true and correct to the best of your knowledge? AND do you agree to the following...I understand that my membership with EDReferral is dependent upon my continued status with my certification and or licensing bodies. I agree that if my state board license/registration/certification is revoked, suspended or expired, I will contact EDReferral and provide written documentation as to the reasons.

YES to the above
NO

NOTE: IF YOU DID NOT ANSWER ALL OF THE LAST 4 QUESTIONS, WE WILL HAVE TO CONTACT YOU BEFORE WE CAN PROCEED

Do you have anything you would like to add to your application? (If you add some information about yourself or your mode of therapy, it helps to personalize your listing.)

WHEN YOU ARE FINISHED, CLICK THE "SUBMIT FORM" BUTTON BELOW