
	Get information on eating disorders and treatment.

Professional Contact

The Renfrew Center Resource Network and Mailing Form

Since The Renfrew Center opened 15 years ago, we have actively maintained a database of healthcare professionals who specialize in eating disorders and women's mental health issues.

If you to take a moment to complete the form below we will send you, free of charge, our professional publication The Perspective. We will also notify you of The Annual Renfrew Center Foundation Conference and other Renfrew seminars and workshops in your community. Our network is also used to provide referral information to clients who call The Renfrew Center asking for guidance.

First Name:
Last Name:
Credentials:
Title:
Organization:

Mailing Address
Street Address:
City:
State:
Zip:
Phone:
Fax:
E-Mail:
	Is this address your Work Home Office?

1. Do you wish to be a treatment resource?
Yes No

2. If you treat eating disorders, is it your primary area?
Yes No

3. How long have you been treating eating disorders?
years

4. 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

Other

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

5. Do you work in any of the following environments?
(select as many as applicable)

College

Day Program

EAP

HMO

Hospital

Inpatient Program

Insurance

Private Practice

Intensive Outpatient Program

Managed Care Company

Residential Program

School

Transitional Living

Outpatient Program

Other

6. Please check which patient populations you treat:

Children (12 and under)

Adolescents (13-17)

Families

Athletes

Couples

Adults

Men

Women

Other

7. Please check ALL areas in which you specialize:

Abuse—physical, sexual, emotional

Alcoholism

Anxiety

Body Image Issues

Chemical Dependency

Compulsive Overeating

Depression

Dissociative Disorders

Eating Disorders

Family Therapy

Gay/Lesbian/Bisexual Issues

Grief and Loss

Group Therapy

Hypnosis

Infertility

Nutrition/Dietetics

Marital/Relationship Issues

Obesity/Large Women's Issues

Obsessive Compulsive Disorder

Panic Disorder

Phobias

PTSD (Post-Traumatic Stress Disorder)

Self-Injurious Behavior

Sexual Addiction

Spirituality

Stress Management

Suicide

Violence

Women's Issues

8. If a therapist, when did you begin practicing?
Year:

9. If you are a therapist in private practice, please describe your orientation and approaches used:

10. How often do your patients require residential treatment for eating disorders?
Never Occasionally Frequently

11. Have you ever attended The Renfrew Center Foundation Conference?
Yes No

12. Where did you hear about us?

13. Have you ever used The Renfrew Center as a resource for your clients?
Yes No

14. What language(s) do you speak?

English	Chinese	Korean
Spanish	French	Vietnamese
Other

15. In what language(s) do you conduct therapy?

English	Chinese	Korean
Spanish	French	Vietnamese
Other

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Professional Contact

The Renfrew Center Resource Network and Mailing Form

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