Organization-Level Membership

Membership Level: First Name: Last Name: Job Title: Email: Home Phone: Home Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix Credentials Company Name Business Website/Social Media Handle (if none, please enter n/a) Business Address Business Phone Is this an organization or individual private practice? Organization (non-profit, hospital, etc.) Individual Private Practice Which county region do you serve/work in? (check all that apply): Which of the following do you or your organization offer? Check all that apply If you offer consults, please describe: Do you offer Virtual / Remote / Telehealth services? Other: What types of insurance do you accept? If other: In what languages are services provided? If other: Do you have experience or feel comfortable serving parents with disabilities? (Ex: After the birth of their child to help them adapt to parenting with a disability and/or coming up with new solutions and techniques to be able to care for their child) If you offer support groups, please share the information below (days/times, location, cost, languages, where to sign up, virtual, etc): If you are joining the Resource Guide, please share a brief summary highlighting key services you offer for listing description. Please choose your words wisely as this is what will be printed and viewed by community members. (350 charactar max) Would your organization like copies of the latest Resource Guide? How many? English? Spanish?