Membership Application

Professional Membership

$100.00

Associate Membership

$75.00

Student Membership

$50.00

Organizational Membership

$200.00

Full Name

Title

Organization

Street Address

Street Address 2

City

State/Province

Zip/Postal Code

Work Phone

Fax Number

Home Phone

E-mail

(Please list the email you would like to be used on our Google group)

FOR ORGANIZATIONAL MEMBERS: Please list one additional contact from the organization.

Please include first and last name and email address.

Website

How did you hear about CTEDS?

Professional Information

Professional Titles (check all that apply):

Other Profession:

Education

Please provide details about your education, including institutions and degrees you receieved:

Undergraduate

Graduate

Additional Education

Licensed By

License Number

Certified By

Certification Number

Legal

Have you ever been convicted of a misdemeanor or felony?

Yes

No

Do you have any pending misdemeanor or felony charges?

Yes

No

Have you ever been publicly reprimanded or disciplined by a professional licensing agency or board or are you aware of any pending investigations or complaints?

Yes

No

Has your professional liability insurer ever placed conditions or restrictions on your coverage or ability to obtain coverage?

Yes

No

Are you aware of any potential malpractice suits that may be filed against you?

Yes

No

Please mail any additional documentation with comments, if needed, to Membership Committee Chair.

Practice Parameters

Number of years in practice?

Number of years of training in disordered eating?

Number of years as an eating disorder specialist?

Population(s) served (Mark all that apply):

Other populations served:

Diagnoses/issues treated (Mark all that apply):

Other diagnoses:

Do you work with clients who have more than one diagnosis?

Yes

No

Treatment setting (Mark all that apply):

Other treatment setting:

Treatment Model (Mark all that apply):

Other treatment model:

Do you have sliding scale fees?

Yes

No

Do you take Insurance?

Yes

No

If so, then which insurance panels are you on?

Please list all other professional organizations of which you are a member:

Values Statements
As an organization, we are:

1. Firmly HAES® aligned (HAEScommunity.com), fat positive, and inclusive

2. Committed to anti-racist learning, growth, and action, and strive to uphold anti-oppressive frameworks

3. LGBTQ+ affirming

4. Affirming of all gender identities and expressions

5. Social justice oriented

Our goal is to strive to cultivate greater safety for marginalized individuals while also creating a brave space for our members to learn and grow.

By checking the box below, each of us is committing to the values statements above, and we are agreeing to represent ourselves in professional and public environments, including in person, virtually and online, according to these values. At the discretion of the board, any harmful statements or actions may result in the requirement of open discussions about the harm in question, and engagement in accountability processes. The board may also take further action, such as removal from the CTEDS website and/or withdrawal of membership.
Applications may take up to 14 business days to process.
*

I agree

I understand I will be added to the CTEDS listserv and am able opt out of this at any time.