AEDS Membership Application

Full Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Fax number
Home Phone
E-mail
URL

Professional Information:

Your professional title: (Choose all that apply)

          Not a Professional (please provide details below) Registered/Licensed Dietitian Licensed Professional Counselor Licensed Social Worker Psychiatrist Nurse/Nurse Practitioner Student supervised by one of the above Other (include title below) Licensed Marriage & Family Therapist Psychologist Physician      

If you answered "other" to title please provide details:

Please provide details about your education, including institutions and degrees you receieved:

Undergraduate

Graduate

Graduate

Additional Education

    Licensed by:

    License #:

    Certified by:

    Certification #:

Please answer the following and attach a separate word file if any answers need explanation.

Have you ever been convicted of a misdemeanor or felony?

        Yes    No

Do you have any pending misdemeanor or felony charges?

        Yes    No

Have you ever been publicly reprimanded or disciplined by a professional licensing agency or board or are you aware of any pending investigations or complaints?

        Yes    No

Has your professional liability insurer ever placed conditions or restrictions on your coverage or ability to obtain coverage?

        Yes    No

Are you aware of any potential malpractice suits that may be filed against you?

        Yes    No

Please mail any additional documentation with comments, if needed, to Membership Committee Chair.

Practice Parameters:

Number of years in practice? 

Number of years of training in disordered eating? 

Number of years as an eating disorder specialist?

Population(s) served: (Mark all that apply)

    Children                Adults

    Athletes                Young Adults (16+ yrs)

    Families                College Students

    Adolescents           Couples

Diagnoses/issues treated: (Mark all that apply)

   Anorexia                                     Body dysmorphic disorder

    Substance Abuse/ Addiction          Night eating  

    OCD                                          Bulimia

    Obesity                                      Anxiety

    Sexual Abuse                              Binge Eating

    Major Depression                         PTSD

    Self Injury                                  Depression

    Other  

Do you work with clients who have more than one diagnosis? Yes  No

Treatment setting: (Mark all that apply)

    Inpatient

    Outpatient

    Private practice

    Community mental health

    School/college counseling program

    Other

Treatment Model: (Mark all that apply)

    12 Step                                   Medical

    Cognitive Behavioral                 Christian Integration

    Interpersonal                           EMDR

    Psychodynamic                         Nutritional

    Biopsychosocial                             Other 

    Dialectical Behavior Therapy

Fees:

Do you have sliding scale fees?  Yes  No

Do you work with Medicare/Medicaid   Yes  No 

Do you take Insurance?  Yes   No

If you do accept Insurance, please list plans:

Please list all other professional organizations of which you are a member:

How did you hear about AEDS?

Please select your level of Membership:

Professional ($50)        Student/Associate Member ($25)

Please e-mail with any questions about this form to Bridget McCauley

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