Provider Application

Provider Application

To be listed in the IDA Dyslexia Services provider directory you must first submit this application. Your application will be reviewed and you will be notified when your listing has been added to this directory. If you have any questions about the IDA Dyslexia Services provider directory, please contact us here and we will reply as soon as possible. Thank you.

 

1. Login Profile

To add your professional listing to this directory and update it at any time in the future, you’ll need to create this account first by completing this application. If you already have an account, then enter the email and password used to setup your account and you’ll automatically be able to update your listing whenever you want. If you’re setting up your account for the first time, then enter an email and password you’ll want associated with your account to login.

2. Public Contact Data

This field is for personal names not company names. Company information can be referenced in the bio section.

Upload a 100 pixel square close cropped head shot in .jpg form here.

3. Location

Start typing your address here to locate your location in this Google Map. Once it appears in the drop-down select it to pinpoint your location. This will appear on the map when a site visitor locates you on the resulting search map.

The entries you make here will locate you on a map and help each visitor determine your proximity to themselves when they conduct a search for providers closest to them. If you choose to only offer virtual services, then this information is not relevant.

4. Services

Scroll and check all that apply.

Select all that apply.

Please list non-English languages in which you provide services.

A check indicates that you are accepting new clients.

I hereby acknowledge that I observe and practice the Ethical Standards as described in the Knowledge and Practice Standards. (To view the Knowledge and Practice Standards, please visit: https://dyslexiaida.org/knowledge-and-practices/)

5. Biography

Please copy and paste a brief professional biography here.

Please upload a PDF file here (3MB Max).

File name:

File size:

1

Upload a PDF file here (3MB max)

File name:

File size:

+ Add Certifications

Please upload a scan of your State License here.

File name:

File size:

6. Sign and Submit

Feel free to click to previous tabs to review the answers you’ve provided here on this application before you click “Submit.” Do not use the back button in your browser address bar. Update anything now before signing the e-signature below. Once you’re satisfied please type your name in the “E-signature” field designating your approval and authorization.

A check indicates that you do agree to public search and display.

* You must enter data in this field.