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 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.

Contact 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?

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

Yes
No

onMouseOut="MM_swapImgRestore()" onMouseOver="MM_swapImage('Graduates','','/images/StructureHouseGraduates.jpg',1)"> Structure House Graduates Call (800)553-0052 or Email

Structure House Graduates Call (800)553-0052 or Email

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