Survey - Treatment Listing Sign Up 2023 - National Eating Disorders Association

Treatment Listing Sign Up 2023

*1.	Question - Required - Name
*2.	Question - Required - Email
	Contact information for practice/treatment facility
*3.	Question - Required - Street 1
4.	Question - Not Required - Street 2
*5.	Question - Required - City
*6.	Question - Required - State/Province
*7.	Question - Required - ZIP/Postal Code
*8.	Question - Required - Phone number
*9.	Question - Required - Please provide the name that will appear on the referral page (e.g.- Jane Smith, Ph.D. or Dr. Jane Smith or Smith Treatment Center). (Maximum response 255 chars, approx. 5 rows of text)
*10.	Question - Required - If you are an individual clinician, are you fully licensed for independent practice in your state? If you are a treatment center/program, are you fully licensed per the guidelines in your state? *At this time we are not able to list providers who are unlicensed, or must work under a supervisor.
11.	Question - Not Required - Do you have multiple treatment locations?
12.	Question - Not Required - If you answered "Yes" to the previous question, how many additional locations?
13.	Question - Not Required - If applicable, please provide the address and phone number of the other treatment locations.
14.	Question - Not Required - Do you offer the same treatment and services at your other locations?
*15.	Question - Required - How did you hear about NEDA's treatment provider listings?
16.	Question - Not Required - If you have any questions or comments, please leave them in the space below.
	If you have any further questions regarding this form or your treatment listing, please contact us at tplisting@nationaleatingdisorders.org or by phone at (212) 575-6200.