Teaming for Clients with One of the Three Ds Registration

Name *

• First
• Last

Address *

• Street Line 1
• Street Line 2

• City
• State Select 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 Non-U.S.

• Zip/Postal code

Phone *

• (###)
• ###
• ####

Email Address *

License Type *

• Counselor
• Hospital Administrator
• Nurse
• Occupational Therapist
• Physical Therapist
• Psychologist
• Social Worker
• Other (please note)

If other was selected above, please note license type

Special Services

• Need wheelchair seating
• Other (please note)

If other was selected above, please note special service