Prospective Patient Form

Basic Information

Name
Enter date in the YYYY-MM-DD fomat.
Mailing Address
Location of Interest
Person Completing This Form

Insurance Information

Insurer
Enter date in the YYYY-MM-DD fomat.

Outpatient (Treatment) Team Information

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