Survey - Treatment Listing Sign up - National Eating Disorders Association

1.

Contact Information


	Title:
*	First Name: Required
*	Last Name: Required
*	Email: Required
*	Street 1: Required
	Street 2:
*	City: Required
*	State / Province: Required
*	ZIP / Postal Code: Required
*	Phone Number: Required
	Yes, I would like to receive e-mail from National Eating Disorders Association
	Yes, I would like to receive postal mail from National Eating Disorders Association
	Keep me logged in. What's this? Remembers your login information for your convenience. Use only on trusted, private computers. Privacy Policy

Do not use your email address as your username for privacy reasons.

*	User Name: Required	5 to 60 characters
*	Password: Required	5 to 99 characters
*	Repeat Password: Required

*2.

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)

*3.

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.

4.

Question - Not Required - Do you have multiple treatment locations?

5.

Question - Not Required - If you answered "Yes" to question 3, how many additional locations?

6.

Question - Not Required - If applicable, please provide the address and phone number of the other treatment locations.

7.

Question - Not Required - Do you offer the same treatment and services at your other locations?

*8.

Question - Required - How did you hear about NEDA's treatment provider listings?

9.

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.