IDA-MA: Request To Be Listed in "Referral for Services Database"




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Email *
First Name *
Last Name *
Email Address *
Business Phone Number *
Mailing Address (street, town, state, zip code) *
Are you a member of the International Dyslexia Association (IDA)? *
IDA Member #
Professional Title/Role *
Required
Qualifications/Certifications *
Required
Age Served *
Required
As a provider, would you be willing to attend school meetings?
Clear selection
As a provider, would you be willing to testify at hearings, etc.?
Clear selection
Do you accept any insurance for your services?
Clear selection
Areas of Competence *
Required
Educational Background: Highest Degree Earned *
Educational Background: Institution Attended *
Educational Background: Highest Degree -- Year Earned *
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Professional Experiences: List Place of Employment and Role *
Wait time for evaluation/services (please report specifying # days/weeks/months as appropriate) *
By my digital signature below, I certify and attest that all the statements and representations I have made in this form are true. Additionally, I certify and attest that I have not been convicted of any felony or crimes involving professional malfeasance, abuse of any kind, or crimes against persons. I have passed the MA State background check and can provide evidence of this, should I be asked. I also acknowledge that a disclaimer will accompany any information disseminated by MABIDA which indicates that all service providers listed in the database have signed this verification statement. I understand that listing in the MABIDA database requires membership in IDA and is at the COMPLETE AND SOLE DISCRETION of MABIDA. By submitting this application, I agree to accept MABIDA’s determination regarding this request to be listed. *
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