Contact us at: ----------------------------- (425) 451-1134 P. (425) 451-8501 F. 1601 114th Ave S.E., Suite. 180 Bellevue, WA 98004
First Name:
Last Name:
Title:
Credentials:
Organization:
Mailing Address:
Street Address:
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Phone:
Fax:
Email:
Do you wish to be a treatment resource?
If you treat eating disorders, is it your primary area?
How long have you been treating eating disorders?
Years:
Which of the following professional types describes you best? (maximum two choices)
Academic Researcher Nutritionist Physician Assistant Trainer Dentist Physician Discharge Planner Psychiatrist Family Medicine Gastroenterology/Bariatric OB/GYN Pediatric Sports Medicine Nurse Nurse Practitioner Psychiatric Nurse Coach Therapist Psychologist Social Worker Counselor Renfrew Staff Licensed Family Therapist Licensed Mental Health Counselor Licensed Marriage and Family Therapist Certified Addiction Professional Other :
Do you work in any of the following environments? (select as many as applicable)
College Intensive Outpatient Program Day Program Managed Care Company EAP Residential Program HMO School Hospital Transitional Living Inpatient Program Outpatient Program Insurance Private Practice Other:
Please check which patient populations you treat:
Children (12 and under) Adults Adolescents (13-17) Men Families Women Athletes Couples Other:
Please check ALL areas in which you specialize:
Abuse—physical, sexual, emotional Infertility Alcoholism Nutrition/Dietetics Anxiety Marital/Relationship Issues Body Image Issues Obesity/Large Women's Issues Chemical Dependency Obsessive Compulsive Disorder Compulsive Overeating Panic Disorder Depression Phobias Dissociative Disorders PTSD (Post-Traumatic Stress Disorder) Eating Disorders Self-Injurious Behavior Family Therapy Sexual Addiction Gay/Lesbian/Bisexual Issues Spirituality Grief and Loss Stress Management Group Therapy Suicide Hypnosis Violence Women's Issues
If a therapist, when did you begin practicing?
Year:
If you are a therapist in private practice, please describe your orientation and approaches used:
How often do your patients require residential treatment for eating disorders?
Have you ever toured The Moore Center?
Where did you hear about us?
Friend Associate Relative Colleague Please Choose
Have you ever used The Moore Center as a resource for your clients?
