Service Referral Search Application Step 1 of 6 16% Name* First Last Are you a current IDA member?*YesNoUnsure Please join or renew your IDA membership here. Once your membership has been completed, please return to fill out this Service Referral Database Application.Please send an email to us at norcal@dyslexiaida.org to inquire about the status of your membership. Personal InformationProfessional TitleEducational Degree(s) click "+" to add another degreeEducational Major(s) click "+" to add another majorEducational Certification(s) click "+" to add another certification Business InformationBusiness NameProfile ImageAccepted file types: jpg, png, gif.Accepted file types: .jpg, .png, .gif Service InformationType of Service* Assessment Intervention Assessment Services Provided* Psycho-Educational Evaluation Psycho-Linguistic Evaluation Neuro-Psychological Evaluation Academic Evaluation Speech & Language Evaluation Medical-Psychological Evaluation Intervention Services Provided* Academic Tutoring Speech-Language Pathology Occupational Therapy Learning Center Multisensory Structured Language Approach*YesNoType of MLS Training* Alphabetic Phonics The Association Method Language! Lindamood-Bell Orton-Gillingham Project Read Slingerland The Spaulding Method Starting Over Wilson Reading Program Reading Reform Preventing Academic Failure Other Other MLS Training click "+" to add another field Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact InformationPhone*FaxEmail* Website TwitterFacebook Google+ In conjunction with submitting this information, I certify and attest that all statements and representations I have made in this form are true and correct, and that I have the credentials, education, degrees, licenses and/or certifications that are legally or customarily required to perform the services I have indicated on this form. Additionally, I certify and attest that I have not been convicted of any felony or any crimes involving professional malfeasance or abuse of any kind.Check to Continue*I agree Share this page with your friends…