EDRS Treatment Fund Application
Name: ___________________________________________________________________________________
Address: _________________________________________________________________________________
Phone: ___________________________________________________________________________________
Name of Mental Health Care Provider / Registered Dietitian / Group Facilitator: __________________________
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Address for Provider: ________________________________________________________________________
Phone for Provider: _________________________________________________________________________
Provider Licence Number:____________________________________________________________________
Fee for Service: _____________________________ Total Fun Request:_______________________________
Please state your reason for seeking treatment and your financial needs below.
Additionally, please include an annual tax document, a W2, or a current pay stub along with your application.
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Please list any additional information that would be helpful to know below.
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Applicant must have a diagnosis of an eating disorder, or be seeking an assessment for one. Funds will be provided upon approval, directly to the licensed treatment provider. Please print this form, fill it out, and return by mail with an annual tax document, a W2, or a current pay stub to:
EDRS Treatment Fund Application
Attn: Joan Thompson
c/o Ronnie Benjamin, MPH, RD
320 Western Avenue
Petaluma, CA 94952
Received: ________________ Reviewed: ________________ Response Sent: ________________
