EDRS Treatment Fund Application Form
Name: ____________________________________________________________________
Address: ___________________________________________________________________
Phone: _____________________________________________________________________
Name of Mental Health Care Provider / Registered Dietitian / Group Facilitator: __________________________________________________________________
Address for Provider: _________________________________________________________
Phone for Provider: ___________________________________________________________
Fee for Service: ______________________________________________________________
Total Fund Request:___________________________________________________________
*Reason for seeking treatment, and financial need:__________________________________
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Additional Information:
*Applicant must have a diagnosis of an eating disorder, or be seeking an assessment for one.
Please print out, fill in and return by mail to EDRS Treatment Fund Requests c/o Haleh Kashani Ph.D. 1330 Lincoln Avenue, Suite 109, San Rafael, CA, 94901
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