Prospective Patient Form

Your Information

Person Completing This Form
Enter date in the YYYY-MM-DD fomat.
By entering in your telephone number, you agree to receive transactional SMS notifications and reminders from ERC and Pathlight via short code 73821. Message and data rates may apply. Message frequency may vary. You may receive alerts until you choose to opt out of this service by texting STOP to 73821 or replying STOP to any of our messages. Text HELP to 73821 for assistance.
Mailing Address

Treatment Information


Insurance Information

If you have government insurance (Medicare/Medicaid/Tricare), we first need to speak with the case manager at your insurance company. Rather than completing this form, please have your case manager contact us at 1-877-920-2902.
Learn about additional treatment options and resources that you may be eligible for here.

If you are not currently insured, please learn about additional treatment options and resources that you may be eligible for here rather than submitting this form, or call us at 877-825-8584.

Enter date in the YYYY-MM-DD fomat.

Current Treatment Team Information

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Eating Recovery Center is accredited through the Joint Commission. This organization seeks to enhance the lives of the persons served in healthcare settings through a consultative accreditation process emphasizing quality, value and optimal outcomes of services.

Organizations that earn the Gold Seal of Approval™ have met or exceeded The Joint Commission’s rigorous performance standards to obtain this distinctive and internationally recognized accreditation. Learn more about this accreditation here.

Joint Commission Seal