Advancing the Education, Prevention, Research & Treatment of Eating Disorders

Professional Contact Form

The Renfrew Center Resource Network and Mailing Form

Since The Renfrew Center opened in 1985, we have actively maintained a network of healthcare professionals who specialize in eating disorders and women's mental health issues.

If you take a moment to complete the form below we will send you, free of charge, our professional publication The Perspective when our next issue is complete. 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.

If you are already a member of our professional network but have changed address, this form can also be used to update your mailing information.

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	Intensive Outpatient Program
Day Program	Managed Care Company
EAP	Residential Program
HMO	School
Hospital	Transitional Living
Inpatient Program	Outpatient Program
Insurance	Other
Private Practice

6. Please check which patient populations you treat:

Children (12 and under)	Adults
Adolescents (13-17)	Men
Families	Women
Athletes	Other
Couples

7. 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

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?

If you chose "Other," please fill in:

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

If you chose "Other," please fill in:

Professional Contact Form

The Renfrew Center Resource Network and Mailing Form

Mailing Address