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. *
I give permission for the above details to be published on PDA North America’s website *

I understand that publication does not represent an endorsement of my services or any further connection between myself/my organization and PDA North America. *
I understand and agree that my/my organizations listing is not affiliated with PDA Society and does not give myself or my organization the rights to use PDA North America’s name or logo *
I understand that PDA North America does not recommend or quality assure services that are included on the public list of organizations. *

I agree to inform PDA North America within 2 weeks, if my organization or I experience any reputational loss or any significant complaints, regulatory issues or safeguarding. *

I agree to inform PDA North America (info@pdanorthamerica.org) if I would like my details to be removed from the list of providers

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Do we have your permission to add you to our PDA North America newsletter?
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Would you be interested in doing a webinar with PDA North America? If so, what would you be interested in talking about?
Are you willing to provide consultations about urgent situations?
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Is there anything else that we should know about you?
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