Addiction Resource Guide

Eating Disorders Directory Information Questionnaire
Directions: Print out the following questionnaire. Fill it out completely and accurately, to obtain a FREE Eating Disorders Directory listing. If you have questions, please email, Polly Waldman at pbw@addictionresourceguide.com. Fax the completed form to 914.631.8077 or mail it to Addiction Resource Guide, P.O. Box 8612, Tarrytown, NY 10591, Attn: Polly Waldman.

Facility Name ___________________________________________________

Please check (ONLY ONE) which Program Type best describes your facility.

[ ] Freestanding Inpatient Facility

[ ] Freestanding Outpatient Facility

[ ] Psychiatric Hospital with Eating Disorder Patients Housed Separately

[ ] Psychiatric Hospital with Integrated Eating Disorder Treatment

[ ] General Hospital with Separate Eating Disorder Rehab Unit

[ ] Long Term Residential Program



Number of Beds ________________

Last Year's Admissions:

Total Number: Adolescents _______________ Adults ________________

Average Length of Stay ________________

Percent of Women ________________

Percent under 25 ________________

Percent covered by Public Assistance ________________

Percent with College Education (estimate) ________________

Percent receiving some form of psychiatric
medication ________________

Admissions Procedures:
Night Admission Available YES NO
Weekend Admission Available YES NO
Face to Face Interview or exam required before admission YES NO


Self Statements: Please describe the following in ONE SENTENCE.

1. Facility's inpatient (outpatient) program.







2. Program's treatment philosophy.







3. Program's position on 12 Step involvement.







4. Your Family Program.







5. Is your approach different for compulsive overeating compared to anorexia/bulimia?







6. Are there restrictions in the kinds of people you accept for treatment? (for example, age, sex)
YES NO
If YES, please explain.







7. List any additional characteristics that distinguish your program.








Payment Information
Self-pay Cost per Week
Public Assistance coverage may be accepted YES NO
Medicare Coverage accepted YES NO
Insurance Coverage verified before admission YES NO
Follow-up Care included at not additional charge YES NO

Licensing and Accreditation (MUST COMPLETE)

Licensed by: ______________________________________

Type of License ___________________________________

Accredited by _____________________________________



Contact Information

Admissions Telephone Number: _____________________

General Telephone Number: ________________________

Address __________________________________________

__________________________________________



Contact Person for future update and WEB related Business

Name: ___________________________________

Title: __________________________________

E-mail address: _________________________

Fax Number: _____________________________

Do you have a Website, and if so, what is your URL?_____________________


FAX COMPLETED QUESTIONNAIRE TO:

or mail it to same at:


© Addiction Resource Guide 2011



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