Diagnostician Referral Application

Name *

First Name

Last Name

Applicant's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer/Practice address (if different than applicant address)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you a member of Everyone Reading Illinois? *

Yes

No

If approved, may we list your email address as a point of contact? (along with preferred contact phone number) *

Yes

No

Member Affiliation *

ACA

AERA

APA

ASHA

IDA

CEC

ISPA

NASP

Other (not below)

Grade Levels *

Elementary

Jr. High

High School

Adult

Assessments Performed In (check all that apply): *

Office

Child's Home

Child's School

Test Batteries You Are Qualified to Perform *

Neuropsychological

Psychiatric

Psychoeducational

Speech/Language

Bilingual Evaluator? (list languages below)

Assessment Course - Achievement

Undergraduate

Graduate

Other

Assessment Course - Intelligence Testing

Undergraduate

Graduate

Other

Basic/Introduction Tests and Measurements

Undergraduate

Graduate

Other

Career Assessment

Undergraduate

Graduate

Other

Child Development

Undergraduate

Graduate

Other

Learning Disabilities - Characteristics

Undergraduate

Graduate

Other

Learning Disabilities - Methods

Undergraduate

Graduate

Other

Neuropsychological Assessment

Undergraduate

Graduate

Other

Reading

Undergraduate

Graduate

Other

Statistics

Undergraduate

Graduate

Other

Use of Tests in Counseling

Undergraduate

Graduate

Other

Are you certified in this method?

Yes

No

Are you certified in this method?

Yes

No

Are you certified in this method?

Yes

No

Are you certified in this method?

Yes

No

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country