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Referral listing is at the sole discretion of IDA. By submitting this application, I agree to accept IDA's determination. IDA memberships will be indicated in the directory.

1. Organization/Professional Name: _________________________________________

Contact Name: ________________________ Title/Position: ___________________

Business Address: _____________________________________________________

Phone: ___________________ Email Address: _____________________________

Website Address: _________________________________

2. Type of services offered:

A. ___ School ___ state licensed/Accredited facility, accreditation #___________

B. ___ Lawyer ___ Psychologist ___ Psychiatric ___ Social Worker

___ Learning Disabilities Diagnostician ___ Education Consultant

___ Other ___________________ License # (if applicable) _____________

C. ___ Teacher Training /Center ___ Hospital /clinic ___ Learning Center

___ Other _______________________________

D. ___ Learning/Remediation Specialist ___ Tutor of Academic Subjects

___ Speech Language Therapist ___ Other ___________________________

3. Have you completed training in any one of the multi-sensory structured language approaches? If yes, list name of approach, date of training, and certificates held: _______________________________________________________________

________________________________________________________________________________________

4. Please describe the areas in which you can provide assistance. (Attach additional sheet if necessary)

Clientele: Remediation: Assessment:

Children ___ Reading ___ Neuropsychological

___ 0-5 ___ Writing ___ LD

___ K-6 ___ Math ___ Add/ADHAD

___ 7-12 ___ Speech/Language ___ Behavioral

___ College-aged ___ Counseling ___ Severe Disabilities

___ Adults

Nature of Services:

_____Academic Tutoring

Additional information: ___________________________________________________________________

______________________________________________________________________________________

5. Educational Background

Institution Degree Year: __________________________________________________________________

_______________________________________________________________________________________

6. Professional Experience

Place of Employment Professional Role/Title Dates ____________________________________________

______________________________________________________________________________________

7. Are you currently a member of IDA? ____________

Please read the following verification statement carefully:

By my signature below, I certify and attest that all statements and representation I have made in this form are true and that 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 all of the credentials, education, degrees and licenses and/or certifications are current and have been issues 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 disclaimer will accompany any information disseminated by The International Dyslexia Association that indicates that all service providers listed have signed this verification statement.

Signature: _____________________________________________ Date: ___________

Please mail to:

The Washington Branch - International Dyslexia Association

Attn: Information and Referral Committee

PO Box 27435

Seattle, WA 98165

Or email scanned copy with signature to: info@wabida.org