APD Map Data - APDsupport.com
Street address of practice *
If you have more than one practice, please fill out this form for EACH location
City *
State
Zip Code
Country *
Name of Practice *
Contact Name *
Name with credentials (e.g. Angela Alexander, Au.D., CCC-A, MNZAS)
Phone Number *
Please include area code
Fax Number
Please include area code
Preferred E-mail Address *
Alternate Email Address
Profession of Person Administering Services *
Tick as many that apply to your clinic
Required
Payment methods *
Tick all that apply to your clinic
Required
Evaluation Method *
Which model do you use for evaluation?
Therapy Method *
Which model do you use for therapy?
Closest City with an Airport *
Distance to Airport *
What services are provided at your clinic? *
Setting *
Which best describes your clinical setting? (May choose multiples)
Required
Do you provide services over telepractice? *
What is the youngest age you will test for APD or auditory skill deficits? (If you do not provide testing, please type 100.) *
Please add any specialty testing or a comment about your clinic, if you would like to make one:
e.g. We also offer cABR.
If your practice has a website associated with it, what is the web address?
Submit
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