The WV Healthy Resources Directory is being developed to assist individuals and groups in locating healthcare professionals in specific areas of the state that can provide professional assistance, that focus on obesity, physical activity, and nutrition. If you are a healthcare professional in West Virginia and would like to have your name and contact information included in this statewide directory, please complete this form and click submit. Note: There is no fee to have your name listed as a resource in this directory. We will be informing the directory users that some participants may request a fee for their services.

Healthcare Professional

*First Name:		*Last Name:

*Credentials:

*Title:

*Organization/Place of Employment:

*Address:

*City:	*State:	*Zip:

*County:

*Phone:

*Email:

*Professional Title (select one)

*Speciality Areas (choose all that apply)
*Services Offered (choose all that apply, you must select at least one)

Individual Counseling	Group Counseling
Conduct Programs / Workshops

*Submitted By (your name):

*Your Email:

Licensed Dietitian (L.D.)	Physician
Registered Dietitian (R.D.)	Nurse / Nurse Practitioner
Physician Assistant	Psychologist
Certified Health Education Specialist (CHES)	Other(Please List):

Cardiovascular / Hypertension	Diabetes
Nutrition	Wellness
Weight Management	Obesity Treatment
Pediatrics	Behavioral Psychology
Physical Activity / Fitness	Eating Disorders
Other(Please List):