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Service Referral Search Application

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Step 1 of 6

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• Name*
  First Last
• Are you a current IDA member?*
  • Yes
  • No
  • Unsure
• 
  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 Information

• Professional Title
• Educational Degree(s)
  click "+" to add another degree
• Educational Major(s)
  click "+" to add another major
• Educational Certification(s)
  click "+" to add another certification

• Business Information

• Business Name
• Profile Image
  Accepted file types: jpg, png, gif.
  Accepted file types: .jpg, .png, .gif

• Service Information

• Type 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*
  • Yes
  • No
• Type 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 Information

• Phone*
• Fax
• Email*
• Website
• Twitter
• Facebook
• 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

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