K  A  T  F  E  D Knox Area Task Force on Eating Disorders
REFERRAL LIST APPLICATION FORM
Please fill out the form below and send the following: (Address will be included soon)
         Resume or vita
         Summary of credentials, licensing information
         List of continuing education, workshops, seminars attended in the past two years

Check all that apply:
Areas of interest:
  ___  Anorexia
  ___  Bulimia
  ___  Compulsive overeating
  ___  Other (please specify):

  _______________________________________________

Area of support you provide:   ___  Psychological   ___  Medical   ___  Nutritional   ___  Art/creative movement   ___  Adjunctive (please specify):   _______________________________________________

Population served:   ___  Children   ___  Adolescents   ___  Adults   ___  Families

Please fill out the form below exactly as you would like for it to appear on the referral list. If you do not want your e-mail or fax listed, please note that on this form.

Name: ________________________________________________________

Title, Licensing or Credentials exactly as you would like to have them listed:

______________________________________________________________________________________

Name of Practice or Place of Employment: _________________________________________________

Phone: __________________________________________________

Address: ____________________________________________________________________________

City: ___________________________________________ State: _________ Zip: _________________

Fax: ________________________________________________ Posted on referral list? ___Yes ___No

E-mail: _____________________________________________ Posted on referral list? ___Yes ___No