First Name:
Last Name:
Organization:
PO Box:

Street Address:
Suite/Room #:
City:
State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip:
Phone:  
Fax:  
E-Mail:  
Internet:

Group or Practice:
Street Address:
Suite/Room #:
City:
State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip:
Phone #:  

Narrative:

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Degree:
Licensure:
Days:
Office Hours:
Fees:

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Reimbursement: Consumer PaysPrivate Insurance
MedicaidSliding Scale
MedicareOther, see narrative
No Fee

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Area of concentration: Discipline: AdministratorGerontologist
AdvocateMusic Therapist
Arts TherapyNeuropsychologist
AttorneyNurse
AudiologistNutritionist
Behavior AnalystOccupational Therapist
CounselorOptometrist
Dental HygienistPhysical Therapist
DieticianPsychiatrist
Early Intervention SpecialistPsychologist
EducatorRecreation Therapist
Educator/Sex EducationRehabilitation Engineer
Environmental ConsultantSchool Psychologist
Financial PlannerSocial Worker
GeneticistSpeech/Lang. Pathologist

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Specialty/Specialties: AdvocacyInclusion
Assertiveness TrainingIndividual Therapy
Assistive TechnologyInterpretation
Behavior Analysis/disorderMediation
Behavior ManagementNeuropsychology
BiofeedbackParenting Concerns
Case ManagementPersonal Futures Planning
Child and Adolescent IssuesPersonal Injury law
Child/Human DevelopmentPharmacological Treatment
Clinical/DevelopmentalPlay Therapy
Community IntegrationProgram Development
ConsultationPsychometrics
Couples TherapyPsycholinguistics
Disability AwarenessPTSD Combat Trauma
Disability LawPTSD Sexual Trauma
Elder LawPublic Health
EmploymentSensitivity Training
Equipment design/repairSensory Integration
Estate PlanningSex Education
EvaluationSocial Skill Development
FacilitationSSI & SSDI Legal Advice
Family Support/TherapyTeaching
Financial AssistanceTraining: Sex Education
Financial PlanningTransition
Forensic PsychologyTranslation
GeneticsTrusts
Group TherapyTutoring
GuardianshipVietnam Vet Family Therapy
Home Based TherapyVietnam Veteran

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Populations: Attention Deficit Disorder/Hyper Activity DisorderLanguage Impairment
AIDS/HIVLearning Disabilities
Asperger's SyndromeMental Health
Autism SpectrumIntellectual Disabilities
Behavior DisorderMultiple Disability
BlindOther See Narrative
Chemical SensitivitiesPhysical Disabilities
Chronic Health ImpairmentSpeech Impairment
DeafBrain/Head Injury
DepressionVisual Impairment
Dual Diagnosis - ID/MIDevelopmental Disability
Eating DisordersDeafBlind
Elderly Person with disabilitiesPost Traumatic Stress Disorder
Epilepsy/Seizure Disorder

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Access Features: Wheelchair AccessTransportation
ElevatorsSee Narrative
HCP ParkingPub Trans-HCP Access
HCP RestroomsBraille/Tapes etc.
Pub TransportationHome Serv/Delivery
Visually ImpairedServ @ Provider
Hearing ImpairedServ @ Home
Physically DisabledServ @ Work
Medical NeedsServ @ School
Free Transport Other Access Features:

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Geographic Restrictions: Local only
In-state only
Other-see narrative
None

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Languages spoken: AfganiFarsiHmongPunjabi
American Sign LanguageFrenchIranianPushta
ArabicGermanItalianRussian
ArmenianGreekJapaneseSpanish
BengaliGujaratiKoreanThai
Cambodian/KhmerHaitianLaotianUrdu
Cape VerdeanHaitian-CreolePolishVietnamese
Chinese-CantoneseHebrewPortugueseTaiwanese
Chinese-MandarinHindiPortuguese-CreoleSwedish Other Language:

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Age groups served: Infant/toddlerPre-school
Lower ElementaryUpper Elementary
Junior high schoolHigh school
Young adultAdult
Elder

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