Service Provider Directory Registration Form

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celebrating our natural sizes

 General Information – Contact
  Do you wish your email address to be kept confidential:
 Yes
No
  Do you wish your physical address to be kept confidential:
 Yes
No

  Salutation:    
  First name:
  Last name:
  Job title/role:
  Organization:
  Department:
  City:
  Province:    
  Address 1:
  Address 2:
  Country:
  Postal Code:
  Phone number:
  Phone number (toll free):
  Fax number:
  Email address:
  Website:


 Services
  List of services:
   Crisis services
Health promotion/prevention/advocacy
Healthy lifestyle activities & programs
Treatment
  Crisis services description:
  
  Health promotion/prevention/advocacy description:
  
  Healthy lifestyle activities & programs description:
  
  Treatment description:
  
  Treatment types (check all that apply):
   Individual counselling
Family counselling
Marital/couples counselling
Group therapy
Medical supervision
Inpatient program
Outpatient program
Day hospital program
Home visits
Nutritional counselling
Self help or support group
  Self-help/support group details 1 - Facilitated by persons who are recovered or recovering from an eating disorder (check all that apply):
   Anorexia
Bulimia
Anorexia and bulimia
Family member suffering from an eating disorder
Binge/compulsive eating issues
Size, weight and shape preoccupation
Other
  Other details:
  
  Support group details 2 - Facilitated by a health/ education professional (check all that apply):
   Anorexia
Bulimia
Anorexia and bulimia
Family member suffering from an eating disorder
Binge/compulsive eating issues
Size, weight and shape preoccupation
Other size concerns
  Other details:
  
  Food & weight issues worked with: (check all that apply):
   Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder
Disordered eating/weight preoccupation
Other Size Concerns
  We provide services to:
   Males
Females
Children
Adolescents
Adults
Individuals
Family & friends
Students only
Lesbian & Gay positive
  We serve a particular catchment area:
   Yes
No
  Catchment area (details):
  
  Restrictions on service provisions
  
  Our facilities are wheelchair accessible:
   Yes
No
  We provide services in the following language(s):
   English
French
Other
  Other languages:
  
  Cost of services (check all that apply):
   Free
Covered by provincial health care
Low cost/sliding scale
Fee for service
  Fee for services:
  
  Access service by (check all that apply):
   Contacting us directly
Through intake
Referral from doctor
Referral from other service provider
  Credentials of service provider(s):
  
  Personal philosophy on food/weight issues:
   Non-dieting, weight acceptance
Dieting, weight-loss counselling
  Notes:
  


 Qualifications
  Credentials/qualifications (please check all that apply):
   MD
RN
MSW
BA/BSc
MA/MSc
M Ed
PhD
  Other credentials/qualifications:
  
  Do you provide clinical supervision?
   Yes
No
  Do you receive clinical supervision?
   Yes
No
  Experience working with (check all that apply)
   Sexual Abuse
Incest survivors
Addictions
Weight preoccupation
Women only
Cross-culturally
Body image
Women/men in crisis
Women/men in general
Food & weight issues
Men only
Persons of colour