SPD Treatment Directory
Educator Registration Form

"*" Denotes a required field

Name*

Address*

City* State* ZIP*

Country

Phone* Fax

Email* Web Site http://

Certified Yes No

States in Which You are Certified to Teach

Other Specialty Certifications

Education/Training
Begin with baccalaureate or other initial professional education, such as education degree, and include graduate school training.

Institution and Location	Degree	Year(s)	Field of Study

Your Philosophy of Education (please describe)

Number of Years in Education

Number of Years Worked with Children or Adults with SPD

Testing Certifications (please specify)

Consulting Experience (please specify)

Memberships in Professional Associations
(check all that apply)
CEC
NAEYC
NEA
Other (please specify)

Student Information

Age Range of Students

Grade Level of Students

Number of Students with SPD Treated Annually

Typical Size of Waiting List (if any)

Do You Evaluate or Treat Students With Any of the Following Disorders?
(check all that apply)
Attention Deficit/Hyperactivity Disorder
Autistic Spectrum Disorder
Cerebral Palsy
Developmental Delay
Developmental Coordination Disorder
Down Syndrome
Feeding Disorders
Fragile X Syndrome
Learning Disabilities
Psychiatric Disorders (e.g., OCD, ODD, Bipolar, etc.)
Regulatory Disorders
Sensory Impairment (visual or hearing)
Sensory Processing Disorder
Traumatic Brain Injury
Other

Settings in Which You Work

School-Based Practice
	Individual Resource Time at School	Yes No	% of time
	Consultation in the Classroom Setting	Yes No	% of time
	Specialized School for Children with Disabling Conditions	Yes No	% of time
	Regular Education Classroom Setting with Special Needs Children Integrated	Yes No	% of time

Direct Service Setting
	Private Practice	Yes No	% of time
	Hospital-Based Practice	Yes No	% of time
	Home-Based Service	Yes No	% of time
	Other Direct Service Setting	Yes No	% of time
	specify

Type of Service
	Individual Direct Service Therapy	Yes No	% of time
	Group Therapy	Yes No	% of time
	Intensives (one week or more)	Yes No	% of time
	Camp Experience	Yes No	% of time
	Other	Yes No	% of time
	specify

Other
	Specify	Yes No	% of time

Sensory Processing Disorder Training
List the dates and titles of any assessment or intervention courses or workshops related to Sensory Processing Disorder that you have attended or taught in the last five years (list the most recent first).

Date	Title	Instructor	Location

Supervision/Reviews
How often do you receive supervision or participate in structured team reviews of your students? Describe the process.

Other Disciplines That Consult, Treat, Evaluate, or Practice at Your Facility
(check all that apply)
Audiologist
Learning Specialist
Neurologist
Nutritionist
Occupational Therapist
Pediatrician
Physiatrist
Physical Therapist
Psychiatrist
Psychologist
Social Worker
Special Educator
Speech Therapist
Other

Special Equipment and Environment Checklist
(check all that apply)

Physical Environment

Handicap accessible

Equipment arranged for rapid change of physical/spatial environment

Hooks to hang suspended equipment
# of hooks

Rotational devices attached to ceiling
# of devices

Large space for physical activity

Quiet space

Total square footage in treatment rooms

Number of rooms

Safety Features

Mats, cushions, pillows for padding

Equipment adjusts to child's size

Accessible equipment monitored for safe use

Unused equipment stored away from children

Documentation of equipment maintenance and upkeep

Available Equipment

Things to climb on

Props/materials to support engagement in play

Visual targets

Barrel for rolling

Tactile materials

Auditory materials

Therapy balls

Creative and fine motor task material

Props/materials for pretend play and practicing skills

Language props, books, etc.

Music equipment and props

Oral motor supplies

Weighted ball/bean bags

Gross motor toys

Other primary equipment

Additional Features

Written evaluation provided to parent

Written goals and objectives provided to parent

Written progress notes provided to parent

Written discharge summary provided to parent

Flexible scheduling, including late afternoon appointments and Saturdays

Family/parent education included

Home programs included

Intensive programs

Groups

Keep in Touch

Check this box if you'd like to receive occasional news and updates from the KID Foundation.

DISCLAIMER: The KID Foundation provides this data for informational purposes only. This listing does not constitute an endorsement by the KID Foundation. There is no guarantee that the information above is correct, up-to-date, or complete. Do not rely upon or act on the basis of this information without seeking current information from the individual listed. Obtaining this information from this web site does not create or imply that a professional relationship exists between you and the KID Foundation, or the individual listed herein and the KID Foundation or any of its staff. Use of the KID Foundation SPD Treatment Directory is expressly conditioned on your acceptance of the terms of this Disclaimer.

Questions or comments about the SPD Treatment Directory? Please email our Development Director, or call the KID Foundation at 303-794-1182.

The Sensory Processing Disorder Network
www.SPDNetwork.org
The KID Foundation
5655 S. Yosemite Suite 305
Greenwood Village, CO 80111

SPD Treatment Directory Educator Registration Form

The Sensory Processing Disorder Network www.SPDNetwork.org The KID Foundation 5655 S. Yosemite Suite 305 Greenwood Village, CO 80111

SPD Treatment Directory
Educator Registration Form

The Sensory Processing Disorder Network
www.SPDNetwork.org
The KID Foundation
5655 S. Yosemite Suite 305
Greenwood Village, CO 80111