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SPD Treatment Directory

Mental Health Professional Registration Form

"*" Denotes a required field
Name*
Profession*
Address*
City*   State*   ZIP*
Country
Phone*   Fax
Email*   Web Site   http://
Licensed Yes No
States in Which You are Licensed
Practice Specialty Certifications
Education/Training
Begin with baccalaureate or other initial professional education, such as nursing, and include graduate school training.
Institution and Location
 Degree
 Year(s)
 Field of Study
Your Philosophy/Theoretical Framework of Intervention (please describe)
Number of Years in Practice
Number of Years Worked with Children or Adults with SPD
Board Certifications (please specify)
Memberships in Professional Associations
American Academy of Child and Adolescent Psychiatry
American Medical Association
American Psychiatric Association
American Psychological Association
APS
Society for Research in Child Development
NASW
Other (please specify)
Patient Information
Age Range of Patients
Number of Children with SPD Treated Annually
Number of Adults with SPD Treated Annually
Typical Size of Waiting List (if any)
Do You Treat Patients 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
Other Disciplines That Consult, Treat, Evaluate, or Practice at Your Facility
(check all that apply)
Audiologist
Educator
Learning Specialist
Neurologist
Nutritionist
Occupational Therapist
Pediatrician
Physiatrist
Physical Therapist
Psychiatrist
Psychologist
Social Worker
Special Educator
Speech Therapist
Other
Insurance*
Do you accept insurance/Medicaid? Yes No
What types of insurance do you accept?
*Insurance eligibility varies depending on diagnosis and other issues. This information does not constitute a guarantee that any individual will be covered by their insurance policy. It is the family’s responsibility to check with their provider to see if insurance coverage is available under their policy.
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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.

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Greenwood Village, CO 80111