• Live Therapist Support 24/7 · 415.331.1302
  • Provider Contact Form


    Interested in joining our Network of Outpatient Providers?   Whether you specialize in eating disorders, substance abuse, or mental health disorders, we are always looking for local providers that we can refer to.  If you would like to be part of our outpatient network, simply fill out this brief form and tell us a little more about yourself.  We look forward to collaborating with you in helping our patients continue their progress in recovery!

    Contact Information

    Provider Name (required)

    Credentials

    Your Email (required)

    Address(required)

    City(required)

    State (required)

    Zip Code (required)

    Phone

    Mobile (Optional)

    Type of License

    Established (Year)

    Profile Information

    Upload Your Profile Picture(s)

    Website (ex. http://www.google.com )

    Affiliations and/or Certifications:

    Biography Section:

    The following sections are there to help you describe your practice, your treatment approach, your treatment
    philosophy, your preferred therapy techniques, and anything unique about your practice that you would like to
    promote.


    Groups Offered - Title and Description(s)


    Practice Focus (select as many as apply):



    Population Focus



    Mental Health Disorders - General Categories



    Sexuality:



    Treatment Modalities (select as many as apply):


    Financial Information:



    Forms of Payment Accepted:

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    Patient Referral

    To refer a patient, please provide your contact information below, and our admissions coordinator will be in touch with you shortly. You may also reach admissions by phone at 415.331.1302.
    Clinician's First Name*