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
|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)
If YES, please explain.
7. List any additional characteristics that distinguish your program.
|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 _____________________________________
Admissions Telephone Number: _____________________
General Telephone Number: ________________________
Contact Person for future update and WEB related Business
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: