Affiliate Provider Information Form

Begin Affiliate Provider Information Form Reason for Contact
Affiliate Name
Email
Main Phone Number:

Mailing Address Mailing Address (Street):
City:
ZIP/Postal Code:
State/Province:

I am working in Private Practice:
I am working for an Organization:
If yes to organization, which organization:
Insurances Accepted (select all that apply):
Which EBT treatment(s) do you provide? (select all that apply):
Training Details (Please provide information on the dates and trainer or each EBT you are trained in. Please also indicate if you participated in a consultation process following the EBT.):