Bulimia.com
Therapist Directory Group Application

Group Registration Form

Section I: Will be posted online

All information in section I will be posted in your listing. Carefully complete the information in this section, which will be listed in the Therapist Directory. If you don’t want your phone, email, or other data listed, omit them from this section but include them under “Confidential contact info” in Section II.
Company Name:
Address 1:
Address 2 :
City, State Zip:
Phone:
Email:
Metropolitan area you serve:
Website address (a link will be provided):
Year you started treating eating disorders:
Percentage of patients you treat for eating disorders:
Specialties (about 25 words max.) For example: I have treated female and male adolescents and adults with eating disorders since 1996. I run support groups and also work with a nutritionist.:

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Describe your treatment setting & approach (about 150 words max.) Short example: My office is in a professional building, where I maintain a private practice. I use psychotherapy, combining CBT and nutritional guidance.:

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Section II:

This information is for Gürze internal use only and will not be posted.
Contact Name:
   
Are you a member of the Academy of Eating Disorders?: yes no
   
Are you a member of the International Association of Eating Disorders Professionals?: yes no
   
License types, numbers, expiration dates & issuing agency:
   
Have you ever been sued for malpractice?: yes no  
   
Have you ever been arrested?: yes no
   
Have you ever been disciplined by a professional organization or been denied membership?: yes no
 
If you answered yes to any of the above questions, please explain below:
   
Additional comments:

Section III:

Gürze Books will verify the information above prior to posting your directory listing.

After you submit this form, you will be directed to our shopping cart for payment. You will be required to enter a customer number or complete contact information there, as well.

Payment Method:



If you have problems with this form email mark@gurze.net