Treatment Fund Application – Clinician

*indicates a required field

  • To maximize the benefits of this scholarship, we require the administering provider to offer outpatient services at sliding scale rates. By signing this you agree to provide individual sessions at $50.00 per 50 minute individual session, and/or group therapy at $25.00 a session. NOTE: IF AN APPLICANT MISSES A SESSION THE SCHOLARSHIP MAY NOT BE APPLIED TO MISSED APPOINTMENTS.

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 or a formal verification of financial status to:

EDRS Treatment Fund Application
c/o Treasurer, EDRS
911 Lakeville Street, Suite 217
Petaluma, CA 94952