Eating Disorders Treatment Accountability Council

Provider you writing this reference for?*

First Last

Your Name*

First Last

Years in Practice*

Education*

Do you have a valid license to practice*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Are you current an EDTAC member?*

How long have you known this provider?*

How long has this provider worked in the eating disorders field?*

On average for the length of the time, this provider has been working in the ED field, what percentage of their time each week would you say he/she dedicates specifically to the treatment or prevention of eating disorders?*

In your professional opinion, would you describe this individual as a high quality treatment provider?*

Are you aware of any instances where this provider has been reprimanded (by employers, licensing, or professional boards) in relation to concerns regarding their treatment of any patient or client?*

How Many Patients/Clients have you referred to this provider?*

Please provide any additional information you think we should take into account in making our determination for this providers verification request.

Provider Reference Submission