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If these fields are incomplete or invalid, your contact information cannot be added to our referral database.Is this a self-referral?*Yes No Full name of your reference (#1)* Phone Number of your reference (#1)*Email Address of your reference (#1)* Full name of your reference (#2)* Phone Number of your reference (#2)*Email Address of your reference (#2)* First Name of Professional* Last Name of Professional* Professional Degree*DegreeBCBACCC-SLPLMHCMAMDMPTMSWOTR/LPhDPsy.DOtherHiddenIf other degree, please list ProfessionProfessionBehavioristDentistDevelopmental PediatricianEducational AdvocateEducational ConsultantEndocrinologistGeneticistLicensed Mental Health Counselor (LMHC)Life Coach for AdultsNeurodiverse Couples CoachNeurologistNeuropsychologistOB/GYNOpthamologistOccupational TherapistPediatricianPharmacistPrimary Care PhysicianPsychiatristPsychologistPsychopharmachologistPhysical TherapistSocial WorkerSpeech and Language PathologistOtherHiddenIf other profession, please list 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KingdomUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsPrimary Phone Number Primary Phone TypeWork Phone Mobile Personal Phone Landline Personal Phone Email* Email Confirmation WebsiteWebsite URL This professional officially diagnoses Asperger's/Autism*NoYesPlease provide any Asperger/Autism expertise Type of service providedOnly choose the areas where this professional/organization has expertise with individuals with an Asperger/autism profileAdolescent Health Care Adult support/ Social group Advocacy Organization (Legislative) Advocacy: Adults (Personal) Advocacy: Educational Alternative Intervention Asperger/autism organization Assistive Technology College Crisis Intervention Diagnosis/ Evaluation Driver's Education Eating Disorders/ Nutrition Educational Assessment/ Intervention Employment services Executive Functioning Coaching Financial planning Gender Homeschooling Housing Internet/screens Jewish Organizations/services Legal: Criminal Legal: Disability Legal: Education Legal: Elder Legal: Employment Legal: Family Legal: Forensic Legal: Pro-Bono Legal: Trusts LGBTQ+ Life Skills Life Skills: Residential Medical (Adolescent) Mental Health: Anxiety Mental Health: Depression Mental Health: Medication Management Mental Health: OCD Mental Health: PTSD Mental Health: Therapy Mental Health Therapy-CBT Mental Health: Trauma Parent support group Post High School Recreation Respite care Sexuality Social skills groups Spanish speaking State Agency Substance/recovery Theater Transition services Tutoring Women/Girls Population/Age Range ServedSelect all that apply.Children Adolescents Adults Families Couples Spouses/Partners Parents Other HiddenIf other, please describe Insurance AcceptedMedicaid Medicare Private Insurance Sliding Scale I do not accept insurance Other What is your full name?* HiddenIf not a self-referral, what is the last name of person making referral What is your email?* Hidden(not used) What is the relationship between the professional and the person making the referral Please describe your relationship to the resourceWhat is your relationship with this professional?*RelationshipCurrent/Past ClientColleagueFriend/Family MemberStudentOtherAre you willing to be contacted by individuals considering this professional?*Yes No Provide us with an example of how this professional was helpful to you:*Please note that your feedback about this professional may be used publicly on the Asperger/Autism Network website. 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