APD Map Data - APDsupport.com
Sign in to Google to save your progress. Learn more
Street address of practice   (Please note:  this cannot just say "telepractice location" - it needs a physical address for the map even if this is not an actual physical clinic.  Consider using your home address.) *
If you have more than one practice, please fill out this form for EACH location
City *
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
Payment methods *
Tick all that apply to your clinic
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)
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?
Our map has the ability to "filter" results based on the client's needs.  Please select ALL of the items that apply to your clinic *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy