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Therapist Renewal Form

Section I: Please complete your name and any fields that you would like updated online, if you have no changes please click submit in Section II to proceed directly to payment.

Name:
Address 1:
Address 2:
City, State Zip:
 
Company name:
 
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:

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.

 

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

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