PDA North America: PDA-Affirming Provider List Application
We appreciate your interest in being on our PDA-affirming provider list. By filling out this form you are agreeing to have your information listed in our PDA-Affirming Provider List. This list is for ANY service being provided to PDAers that is neurodiverse affirming/PDA affirming. (This can include therapists, doctors, schools, along with any service such as a sports league, swim lessons, etc.) 

The PDA-Affirming Provider List is on our Resources section of the website found here:
 https://pdanorthamerica.org/resources/ 

If you'd like to be removed from this list at any time, please email mjohnson@pdanorthamerica.org

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Email *
If you are a healthcare/mental health provider, do you take medical insurance? 
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What is your name? *
What is your title? What services do you provide? If using acronyms, please write out what it refers to so families will know what services you provide. *
Where are you located? Please note if provide services in-person, remote, or both. or Psypact certified. If you provide services in a particular state or city, list your location. 
Email address you'd like on the listing
What information would you like to be published on our PDA North America PDA Affirming provider list? (email, website, phone number...?) You need to include this information here if you want it published on the website!
Are you PDA Affirming? Please include how you got your information on PDA and/or your relationship to PDA. *
Do we have your permission to be listed on our website (PDA North America) as a PDA affirming provider? *
Do we have your permission to add you to our PDA North America newsletter?
 *
Would you be interested in doing a webinar with PDA North America? If so, what would you be interested in talking about?
Is there anything else that we should know about you?
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