Request for Listing in Referral Services Database

We are pleased to announce that The International Dyslexia Association - Rocky Mountain Branch and the Dyslexia Resource Group now offers a Referral List of local professionals that can help families. If you would like to be considered for the list, please complete and submit the application below.

If you have already filled out this form, please click here for instructions on sending in your resume.

Fields in bold font are required. Address is for internal use – only the city will be published.

Name:

Professional Role/Title:

Place of Employment
(or self employed):

Address:

City:

State:

Zip:

Phone:

Alternative Phone:

Email:

Web Site:

Areas of specialty:
(check all that apply)

Dyslexia ADD/ADHD Other:

Number of years working with dyslexic/LD students:

Services Offered:
(check all that apply)

Qualified to Assess in:
(check all that apply)

IQ Process Achievement Language

Ages you work with:
(check all that apply)

Elementary Middle/High School Adult

Days/Hours Available:

Additional Summer Hours:

Area/Cities You Service:

Services Provided At:
(check all that apply)

My Office/Home Student's Home Student's School

Other Location:

Rates:

List all multisensory language approaches you use in your practice if applicable. You will be asked to attach a resume with trainings, certifications and practicum hours for each. (i.e. Orton-Gillingham, Wilson Reading, LANGUAGE!, etc.)

Please list any other information you think we should have:

Check All That Apply:

Please include me in the IDA-RMB Referral Service Database

Note: Membership is requested to be included on the IDA Referral List. Not a member? Please click here

Please include me in the Dyslexia Resource Group Referral Service Database. Click here to see their web site.

PLEASE READ THE FOLLOWING STATEMENT CAREFULLY BEFORE CHECKING THE BOX:

By checking the box below, I certify and attest that all my statements and representations I have made in this form are true and I have all credentials, education, degrees, licenses and/or certifications that are legally or customarily required in my field to perform the services I have indicated on this form. Further, I certify and attest that the credentials, education, degrees, licenses and/or certifications are current and have been issued by an institution or body accredited or empowered to do so.

Additionally, I certify and attest that I have not been convicted of any felony or crimes involving professional malfeasance or abuse of any kind. I also acknowledge that a disclaimer will accompany any information disseminated by IDA-RMB or DRG that indicates that all service providers listed in the database have signed this verification statement and that neither IDA nor DRG can be held libel for the statements or actions of provider.

By submitting this application, I agree to accept IDA-RMB’s or DRG’s determination regarding this request to be listed.

I agree with these terms