Success StoriesWeight Loss ProgramsTypical Day

Professional Referrals

Structure House participants often express an interest to continue their therapeutic work with local professionals when they leave our campus and transition home. In order to ensure that they will receive the highest quality after-care, we maintain a database of treatment providers who specialize in weight management and related issues.

If you are a treatment professional who would like to be considered for this database, please complete the form below. After submitting your information, you will receive – free of charge – a subscription to our Enlighten Newsletter, a direct telephone number and e-mail address reserved for provider-to-provider communication, and details about how to arrange a visit and tour of our facilities.








Personal Information

First Name
Last Name
Degree/Credentials
Street Address
City, State, Zip
Phone Number (
)
Fax Number (
)
E-mail Address
Check One This is my:    

Home 

Office

Questionnaire

1. What type of treatment professional are you?

  • Psychology
Psychologist (Ph.D, Psy.D)

Social Worker (M.S.W., L.C.S.W)

Licensed Family Therapist

Licensed Marriage and Family Therapist

Certified Addiction Professional

  • Nutrition
Dietician (R.N., L.D.)

Certified Diabetes Educator

  • Medicine
Endocrinologist

General Practitioner

Psychiatrist

Sports Medicine

Orthopedist

Neurologist

Nurse Practitioner

Psychiatric Nurse

Physician’s Assistant

  • Exercise
Exercise physiologist

Personal Trainer

Physical Therapist

Massage Therapist

Academic Researcher

Other

2. Is weight management your primary area of expertise?

Yes

No

3. What approximate percentage of your patient contact is devoted to issues related to weight management?

%

4. How many years have you treated individuals with weight management concerns?

yrs

5. Please indicate the type(s) of setting in which you currently practice

Residential Program

Private Practice (Independent or Group)

Hospital

Community-Based Clinic

University Medical Center

Employee-Assistance Program

Fitness Club

Rehabilitation Facility

University Counseling Center

Resort/Spa

Transitional Living Facility

Other

6. Please tell us about the type of issues that you are proficient in addressing with patients.
(check all that apply)

Depression

Anxiety

Eating Disorders

Trauma

Social Anxiety

Assertiveness Training

Stress Management

Family/Marital Discord

Career counseling

Spirituality/Mindfulness

Grief and Loss

Pain Control

Addictions

Other

7. Have you ever referred a patient to a residential or hospital-based treatment program for weight loss?

Yes

No
If yes, indicate the name of that program

8. Do you accept insurance?

Yes

No
If yes, specify insurance carriers

9. How did you hear about Structure House?

Professional Marketer



Other:

10. Have you ever treated an individual who has completed the Structure House program?

Yes

No

11. Please help us prevent spam by entering the two words below.

 



 

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