Registration

Username *

Please enter your email as your username

Password *

Membership Level *

Group Practice Member (contact Membership@CTEDS.org for more information)

Email *

First Name *

Last Name *

Organization/Group Practice Name (if applicable)

Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Work Phone

Home Phone *

Email *

(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 Title(s) *

Other Profession (if applicable)

Licensed By *

License Number *

Certified By

Certification Number

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

Undergraduate (Institution and Degree) *

Graduate (Institution and Degree) *

Additional Education

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 email any additional documentation with comments, if needed, to Membership Chair (Membership@CTEDS.org).

Number of years in practice *

Number of years working with disordered eating *

Number of years working as an eating disorder specialist *

Population(s) Served *

Other Populations Served

Diagnoses Treated *

Other diagnoses

Treatment Setting *

Other Treatment Setting:

Treatment Model *

Other Treatment Models:

Payment Types Accepted *

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

As an organization, CTEDS is: *

1. Firmly HAES® aligned (https://asdah.org/haes/), fat positive, and inclusive

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

3. LGBTQIA+ 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 boxes above and below, each of us is committing to the values statements, 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.

*

I agree

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

Applications may take up to 14 business days to process.

Fieldset

Professional Information

Education

Legal

Practice

Values Statements

Verification