SPD Treatment Directory
Speech-Language Pathologist Registration Form

"*" Denotes a required field

Name*

Address*

City* State* ZIP*

Country

Phone* Fax

Email* Web Site http://

Completed Clinical Fellowship Year and Obtained CCC Yes No

Location and Date

Licensed Yes No

States in Which You are Licensed (Three states do not have licensure: CO, MI, and WA; speech-language pathologists in these states will not be licensed.)

Practice Specialty Certifications

Education/Training
Begin with baccalaureate or other initial professional education, such as communication degree, and include graduate school degree and Certificate of Clinical Competence if applicable.

Institution and Location	Degree	Year(s)	Field of Study

Your Philosophy of Intervention (please describe)

Number of Years in Practice

Number of Years Worked with Children or Adults with SPD

Number of Years Working in Pediatrics

Testing Certifications (please specify)

Memberships in Professional Associations
ASHA
Other (please specify)

Client Information

Age Range of Clients

Number of Children with SPD Treated Annually

Number of Adults with SPD Treated Annually

Typical Size of Waiting List (if any)

Assessments Administered
(check all that apply)
Bayley Scales of Infant Development
Clinical Evaluation of Language Fundamentals - Preschool
Clinical Evaluation of Language Fundamentals - 4
Comprehensive Assessment of Spoken Language
Language Processing Test
Lindamood Auditory Conceptualization Test
Preschool Language Scale - 4
SCAN Test for Auditory Processing Disorders
Test for Auditory Comprehension of Language
Test of Auditory Perceptual Skills Revised
Test of Auditory Reasoning and Processing Skills
Test of Language Development - 3
Test of Listening Comprehension and Oral Expression
Test of Problem Solving
Other (please specify)

Disorders Treated
(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

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
	describe

School-Based Practice
	Individual Therapy at School	Yes No	% of time
	Consultation in the Classroom Setting	Yes No	% of time
	Small Group Pull-Out Services	Yes No	% of time

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 Available	Yes No	% of time
	Other	Yes No	% of time
	describe

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
Educator
Learning Specialist
Neurologist
Nutritionist
Occupational Therapist
Pediatrician
Physiatrist
Physical Therapist
Psychiatrist
Psychologist
Social Worker
Special Educator
Other

Specific Intervention Strategies Used

Supplemental Programs Offered

Insurance*

Do you accept insurance/Medicaid? Yes No

What types of insurance do you accept?

Equipment and Environment Checklist
(check all that apply)

Physical Environment

Handicap accessible

Quiet space

Total square footage in treatment rooms

Number of rooms

Safety Features

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

Creative and fine motor task material

Props/materials for pretend play and practicing skills

Oral motor supplies

Auditory materials

Tactile materials

Other primary equipment (specify)

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

Groups

Intensive programs

*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.

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

SPD Treatment Directory Speech-Language Pathologist 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
Speech-Language Pathologist Registration Form

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