echoautism.org
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Submitted URL: http://echoautism.org/
Effective URL: https://echoautism.org/
Submission: On November 15 via manual from US — Scanned from DE
Effective URL: https://echoautism.org/
Submission: On November 15 via manual from US — Scanned from DE
Form analysis 34 forms found in the DOM
GET https://echoautism.org/
<form role="search" method="get" class="search-form" action="https://echoautism.org/">
<label>
<span class="screen-reader-text">Search for:</span>
<input type="search" class="search-field" placeholder="Search …" value="" name="s">
</label>
<input type="submit" class="search-submit sc_button_hover_slide_left" value="Search">
</form>GET https://echoautism.org/
<form role="search" method="get" class="search_form" action="https://echoautism.org/">
<input type="text" class="search_field" placeholder="Search" value="" name="s">
<button type="submit" class="search_submit trx_addons_icon-search"></button>
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_3" action="/" data-formid="3">
<input type="hidden" class="gforms-pum" value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div class="gform-body gform_body">
<ul id="gform_fields_3" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_3_1" class="gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_3_1"><label
class="gfield_label gform-field-label gfield_label_before_complex">Your Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row" id="input_3_1">
<span id="input_3_1_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
<input type="text" name="input_1.3" id="input_3_1_3" value="" aria-required="true">
<label for="input_3_1_3" class="gform-field-label gform-field-label--type-sub ">First</label>
</span>
<span id="input_3_1_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
<input type="text" name="input_1.6" id="input_3_1_6" value="" aria-required="true">
<label for="input_3_1_6" class="gform-field-label gform-field-label--type-sub ">Last</label>
</span>
</div>
</li>
<li id="field_3_2" class="gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_3_2"><label class="gfield_label gform-field-label"
for="input_3_2">Your Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_2" id="input_3_2" type="text" value="" class="large" aria-required="true" aria-invalid="false">
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</li>
<li id="field_3_3" class="gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_3_3"><label
class="gfield_label gform-field-label" for="input_3_3">Your Message<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_3" id="input_3_3" class="textarea medium" aria-required="true" aria-invalid="false" rows="10" cols="50"></textarea></div>
</li>
</ul>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_3" class="gform_button button sc_button_hover_slide_left" value="Submit"
onclick="if(window["gf_submitting_3"]){return false;} window["gf_submitting_3"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_3"]){return false;} window["gf_submitting_3"]=true; jQuery("#gform_3").trigger("submit",[true]); }">
<input type="hidden" class="gform_hidden" name="is_submit_3" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="3">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_3" value="WyJbXSIsIjFlNzkzYjUwZGMxMDE0MmVlZDdjYzVmNzkyMTc0ZTAwIl0=">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_3" id="gform_target_page_number_3" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_3" id="gform_source_page_number_3" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
<p style="display: none !important;"><label>Δ<textarea name="ak_hp_textarea" cols="45" rows="8" maxlength="100"></textarea></label><input type="hidden" id="ak_js_27" name="ak_js" value="1700077050386">
<script>
document.getElementById("ak_js_27").setAttribute("value", (new Date()).getTime());
</script>
</p>
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_125" action="/" data-formid="125">
<input type="hidden" class="gforms-pum" value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div class="gform-body gform_body">
<div id="gform_fields_125" class="gform_fields top_label form_sublabel_below description_below">
<fieldset id="field_125_1" class="gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_125_1">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Name</legend>
<div class="ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row" id="input_125_1">
<span id="input_125_1_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
<input type="text" name="input_1.3" id="input_125_1_3" value="" aria-required="false">
<label for="input_125_1_3" class="gform-field-label gform-field-label--type-sub ">First</label>
</span>
<span id="input_125_1_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
<input type="text" name="input_1.6" id="input_125_1_6" value="" aria-required="false">
<label for="input_125_1_6" class="gform-field-label gform-field-label--type-sub ">Last</label>
</span>
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<div id="field_125_3" class="gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_125_3"><label class="gfield_label gform-field-label"
for="input_125_3">Email</label>
<div class="ginput_container ginput_container_email">
<input name="input_3" id="input_125_3" type="text" value="" class="large" aria-invalid="false">
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</div>
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<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_125" class="gform_button button sc_button_hover_slide_left" value="Submit"
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onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_125"]){return false;} window["gf_submitting_125"]=true; jQuery("#gform_125").trigger("submit",[true]); }">
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<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_125" value="WyJbXSIsIjFlNzkzYjUwZGMxMDE0MmVlZDdjYzVmNzkyMTc0ZTAwIl0=">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_125" id="gform_target_page_number_125" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_125" id="gform_source_page_number_125" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
<p style="display: none !important;"><label>Δ<textarea name="ak_hp_textarea" cols="45" rows="8" maxlength="100"></textarea></label><input type="hidden" id="ak_js_1" name="ak_js" value="1700077050437">
<script>
document.getElementById("ak_js_1").setAttribute("value", (new Date()).getTime());
</script>
</p><input type="hidden" name="pum_form_popup_id" value="7097">
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_124" action="/" data-formid="124">
<input type="hidden" class="gforms-pum" value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div class="gform-body gform_body">
<div id="gform_fields_124" class="gform_fields top_label form_sublabel_below description_below">
<fieldset id="field_124_7" class="gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_124_7">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Name<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row" id="input_124_7">
<span id="input_124_7_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
<input type="text" name="input_7.3" id="input_124_7_3" value="" aria-required="true">
<label for="input_124_7_3" class="gform-field-label gform-field-label--type-sub ">First</label>
</span>
<span id="input_124_7_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
<input type="text" name="input_7.6" id="input_124_7_6" value="" aria-required="true">
<label for="input_124_7_6" class="gform-field-label gform-field-label--type-sub ">Last</label>
</span>
</div>
</fieldset>
<div id="field_124_4" class="gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_124_4"><label
class="gfield_label gform-field-label" for="input_124_4">Email<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_4" id="input_124_4" type="text" value="" class="large" aria-required="true" aria-invalid="false">
</div>
</div>
<div id="field_124_6" class="gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_124_6"><label
class="gfield_label gform-field-label" for="input_124_6">What is your interest in our Start an ECHO Program?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_6" id="input_124_6" class="textarea large" aria-required="true" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<fieldset id="field_124_17" class="gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible"
data-js-reload="field_124_17">
<legend class="gfield_label gform-field-label gfield_label_before_complex">ECHO Autism Communities Consent for Publicity: News Release and Photography</legend>
<div class="ginput_container ginput_container_consent"><input name="input_17.1" id="input_124_17_1" type="checkbox" value="1" aria-describedby="gfield_consent_description_124_17" aria-invalid="false"> <label
class="gform-field-label gform-field-label--type-inline gfield_consent_label" for="input_124_17_1">I Consent to ECHO Autism Communities Release Agreement</label><input type="hidden" name="input_17.2"
value="I Consent to ECHO Autism Communities Release Agreement" class="gform_hidden"><input type="hidden" name="input_17.3" value="69" class="gform_hidden"></div>
<div class="gfield_description gfield_consent_description" id="gfield_consent_description_124_17">I hereby consent to the use of my name and image by ECHO Autism Communities to promote its programs statewide/internationally. I hereby give my
permission for said information to be used in both internal and external publications, social media, and videos. </div>
</fieldset>
</div>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_124" class="gform_button button sc_button_hover_slide_left" value="Register"
onclick="if(window["gf_submitting_124"]){return false;} window["gf_submitting_124"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_124"]){return false;} window["gf_submitting_124"]=true; jQuery("#gform_124").trigger("submit",[true]); }">
<input type="hidden" class="gform_hidden" name="is_submit_124" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="124">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_124"
value="WyJ7XCIxNy4xXCI6XCI4ZmUxOTEyYmM2NDdhZjgwMmEwZDY4NWU3OGEyYjA1ZVwiLFwiMTcuMlwiOlwiMGExODU2MDFiMTYzYWRlZTQzMDNkNGI5MmI5MWJmMzdcIixcIjE3LjNcIjpcImVjZTY2MjExYmVjOGIzOTE3ZTczNjI5ZWIyNmY0OTVmXCJ9IiwiNTExMjBhZWYwM2NiNzUzY2QwMTg3NDc2OWJkZTJjOTgiXQ==">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_124" id="gform_target_page_number_124" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_124" id="gform_source_page_number_124" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
<p style="display: none !important;"><label>Δ<textarea name="ak_hp_textarea" cols="45" rows="8" maxlength="100"></textarea></label><input type="hidden" id="ak_js_2" name="ak_js" value="1700077050438">
<script>
document.getElementById("ak_js_2").setAttribute("value", (new Date()).getTime());
</script>
</p><input type="hidden" name="pum_form_popup_id" value="6777">
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_90" action="/" data-formid="90">
<input type="hidden" class="gforms-pum" value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div class="gform-body gform_body">
<div id="gform_fields_90" class="gform_fields top_label form_sublabel_below description_below">
<fieldset id="field_90_7" class="gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_90_7">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Name<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row" id="input_90_7">
<span id="input_90_7_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
<input type="text" name="input_7.3" id="input_90_7_3" value="" aria-required="true">
<label for="input_90_7_3" class="gform-field-label gform-field-label--type-sub ">First</label>
</span>
<span id="input_90_7_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
<input type="text" name="input_7.6" id="input_90_7_6" value="" aria-required="true">
<label for="input_90_7_6" class="gform-field-label gform-field-label--type-sub ">Last</label>
</span>
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<div id="field_90_4" class="gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_90_4"><label
class="gfield_label gform-field-label" for="input_90_4">Email<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_4" id="input_90_4" type="text" value="" class="large" aria-required="true" aria-invalid="false">
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<div id="field_90_6" class="gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_90_6"><label
class="gfield_label gform-field-label" for="input_90_6">What is your interest in our Start an ECHO Program?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_6" id="input_90_6" class="textarea large" aria-required="true" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
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data-js-reload="field_90_17">
<legend class="gfield_label gform-field-label gfield_label_before_complex">ECHO Autism Communities Consent for Publicity: News Release and Photography</legend>
<div class="ginput_container ginput_container_consent"><input name="input_17.1" id="input_90_17_1" type="checkbox" value="1" aria-describedby="gfield_consent_description_90_17" aria-invalid="false"> <label
class="gform-field-label gform-field-label--type-inline gfield_consent_label" for="input_90_17_1">I Consent to ECHO Autism Communities Release Agreement</label><input type="hidden" name="input_17.2"
value="I Consent to ECHO Autism Communities Release Agreement" class="gform_hidden"><input type="hidden" name="input_17.3" value="61" class="gform_hidden"></div>
<div class="gfield_description gfield_consent_description" id="gfield_consent_description_90_17">I hereby consent to the use of my name and image by ECHO Autism Communities to promote its programs statewide/internationally. I hereby give my
permission for said information to be used in both internal and external publications, social media, and videos. </div>
</fieldset>
</div>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_90" class="gform_button button sc_button_hover_slide_left" value="Register"
onclick="if(window["gf_submitting_90"]){return false;} window["gf_submitting_90"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_90"]){return false;} window["gf_submitting_90"]=true; jQuery("#gform_90").trigger("submit",[true]); }">
<input type="hidden" class="gform_hidden" name="is_submit_90" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="90">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_90"
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<p style="display: none !important;"><label>Δ<textarea name="ak_hp_textarea" cols="45" rows="8" maxlength="100"></textarea></label><input type="hidden" id="ak_js_3" name="ak_js" value="1700077050438">
<script>
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<form method="post" enctype="multipart/form-data" id="gform_122" action="/" data-formid="122">
<input type="hidden" class="gforms-pum" value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div class="gform-body gform_body">
<div id="gform_fields_122" class="gform_fields top_label form_sublabel_below description_below">
<fieldset id="field_122_7" class="gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_122_7">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Name<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row" id="input_122_7">
<span id="input_122_7_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
<input type="text" name="input_7.3" id="input_122_7_3" value="" aria-required="true">
<label for="input_122_7_3" class="gform-field-label gform-field-label--type-sub ">First</label>
</span>
<span id="input_122_7_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
<input type="text" name="input_7.6" id="input_122_7_6" value="" aria-required="true">
<label for="input_122_7_6" class="gform-field-label gform-field-label--type-sub ">Last</label>
</span>
</div>
</fieldset>
<div id="field_122_4" class="gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_122_4"><label
class="gfield_label gform-field-label" for="input_122_4">Email<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_4" id="input_122_4" type="text" value="" class="large" aria-required="true" aria-invalid="false">
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</div>
<div id="field_122_6" class="gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_122_6"><label
class="gfield_label gform-field-label" for="input_122_6">What is your interest in our Start an ECHO Program?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_6" id="input_122_6" class="textarea large" aria-required="true" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
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<legend class="gfield_label gform-field-label gfield_label_before_complex">ECHO Autism Communities Consent for Publicity: News Release and Photography</legend>
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<legend class="gfield_label gform-field-label gfield_label_before_complex">ECHO Autism Communities Consent for Publicity: News Release and Photography</legend>
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<p style="color: #000000;">First Name</p>
<input name="FirstName" required="required" type="text" style="width: 100%;">
<br> Last Name <input name="LastName" required="required" type="text" style="width: 100%;">
<br> Email <input name="Email" required="required" type="email" style="width: 100%;">
<br> Phone Number <input type="text" name="Phone2">
<br> Company <input type="text" required="required" name="Company">
<br> Organization address (personal address if not affiliated with an organization) <input type="text" placeholder="Street" name="Address2Street1" required="required">
<input type="text" placeholder="Apt/Suite/Other" name="Address2Street2">
<input type="text" placeholder="City" required="required" name="City2" style="width: 49%; display: inline;">
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<br><br> Password <input type="password" required="required" name="Password">
<br> Which of these fields best categorizes the field you work in? <div class="select_container"><select onchange="yesnoCheck(this);" name="_JobCategory">
<option value="Clinical Intervention">Clinical Intervention (ABA, OT, SLP, etc.)</option>
<option value="Community Support/ Resource Navigation/ Community Resource">Community Support/ Resource Navigation/ Community Resource</option>
<option value="Education">Education</option>
<option value="Family Advocate/Self-Advocate">Family Advocate/Self-Advocate</option>
<option value="Clinical Health/Allied Health">Clinical Health/Allied Health</option>
<option value="Law">Law</option>
<option value="Mental Health">Mental Health</option>
<option value="Non-Clinical Health/ Public Health/ Research">Non-Clinical Health/ Public Health/ Research</option>
<option value="Nursing">Nursing</option>
<option value="Nurse Practitioner">Nurse Practitioner</option>
<option value="Oral Health">Oral Health</option>
<option value="Pharmacy">Pharmacy</option>
<option value="Physician">Physician</option>
<option value="Physician Assistant">Physician Assistant</option>
<option value="Psychologist">Psychologist</option>
<option value="Social Work">Social Work</option>
<option value="Student">Student</option>
<option value="Other">Other</option>
</select></div>
<br>
<div id="ifCI" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_ClinicalInterventionRole">
<option style="display: none;" value=""></option>
<option value="Behavioral Implementer">Behavioral Implementer</option>
<option value="Behavioral Specialist">Behavioral Specialist</option>
<option value="Dietician">Dietician</option>
<option value="Occupational Therapist">Occupational Therapist</option>
<option value="Occupational Therapist Assistant">Occupational Therapist Assistant</option>
<option value="Physical Therapist">Physical Therapist</option>
<option value="Physical Therapist Assitant">Physical Therapist Assitant</option>
<option value="Speech Language Pathologist">Speech Language Pathologist</option>
<option value="Speech Language Pathologist - Assistant">Speech Language Pathologist - Assistant</option>
<option value="Other">Other</option>
</select></div><br>
<br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_ClinicalInterventionCredentials">
<option style="display: none;" value=""></option>
<option value="BCaBA">BCaBA</option>
<option value="BCBA">BCBA</option>
<option value="BCBA-D">BCBA-D</option>
<option value="LBA">LBA</option>
<option value="LABA">LABA</option>
<option value="RBT">RBT</option>
<option value="LD">LD</option>
<option value="OTR/L">OTR/L</option>
<option value="COTA/L">COTA/L</option>
<option value="PT">PT</option>
<option value="PTA">PTA</option>
<option value="CCC-SLP">CCC-SLP</option>
<option value="SLPA">SLPA</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifCS" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_CommunitySupportRole">
<option style="display: none;" value=""></option>
<option value="Certified Peer Mentor">Certified Peer Mentor</option>
<option value="Community Health Worker">Community Health Worker</option>
<option value="Family Advocate">Family Advocate</option>
<option value="Family/Caregiver/Patient Navigator">Family/Caregiver/Patient Navigator</option>
<option value="Program Coordinator/Manager/Supervisor">Program Coordinator/Manager/Supervisor</option>
<option value="Resource Specialist/Resource Navigator">Resource Specialist/Resource Navigator</option>
<option value="Support Coordinator/Service Coordinator">Support Coordinator/Service Coordinator</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifEDUCATION" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_EducationRole">
<option style="display: none;" value=""></option>
<option value="Certified Peer Mentor">Certified Peer Mentor</option>
<option value="Higher Education (non-medical): Professor/Assistant Prof/Associate Prof/Adjunct Prof/Emeritus, etc.">Higher Education (non-medical): Professor/Assistant Prof/Associate Prof/Adjunct Prof/Emeritus, etc.</option>
<option value="Para Professional">Para Professional</option>
<option value="School Administrator">School Administrator</option>
<option value="School Principal">School Principal</option>
<option value="School Teacher">School Teacher</option>
<option value="Other">Other</option>
</select></div>
<br><br> Please provide your credentials related to this field of work <input name="_EducationCredentials" type="text" style="width: 100%;">
<br>
</div>
<div id="ifFA" style="display: none;">
<br> Please select if you have lived experience in the following areas: <br>
<div class="select_container"><select name="_FASALivedExperience">
<option style="display: none;" value=""></option>
<option value="Parent or caregiver of a child or person with autism or other developmental or intellectual disability">Parent or caregiver of a child or person with autism or other developmental or intellectual disability</option>
<option value="Person with autism/ Autistic person">Person with autism/ Autistic person</option>
</select></div>
<br><br> What is your role in that field? <br>
<div class="select_container"><select name="_FASARole">
<option style="display: none;" value=""></option>
<option value="Caregiver">Caregiver</option>
<option value="Certified Peer Mentor">Certified Peer Mentor</option>
<option value="Extended Family / Caregiver Support">Extended Family / Caregiver Support</option>
<option value="Family Advocate">Family Advocate</option>
<option value="Foster Parent">Foster Parent</option>
<option value="Grandparent">Grandparent</option>
<option value="Guardian">Guardian</option>
<option value="Kinship Foster Parent">Kinship Foster Parent</option>
<option value="Parent">Parent</option>
<option value="Parent Partner">Parent Partner</option>
<option value="Self-Advocate">Self-Advocate</option>
<option value="Other">Other</option>
<option value="Guardian">None</option>
</select></div>
</div>
<div id="ifCH" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_ClinicalHealthRole">
<option style="display: none;" value=""></option>
<option value="Clinical Lab Worker/ Med Technologist">Clinical Lab Worker/ Med Technologist</option>
<option value="Electroneurodiagnostic Technologist">Electroneurodiagnostic Technologist</option>
<option value="EMT/ Paramedic">EMT/ Paramedic</option>
<option value="Exercise Science Professional (trainer, physiologist)">Exercise Science Professional (trainer, physiologist)</option>
<option value="Genetic Counselor/Genetic Assistants">Genetic Counselor/Genetic Assistants</option>
<option value="Kinesiotherapist">Kinesiotherapist</option>
<option value="Lactation Consultant">Lactation Consultant</option>
<option value="Magnetic Resonance Technologist (MRI)">Magnetic Resonance Technologist (MRI)</option>
<option value="Medical Assistant">Medical Assistant</option>
<option value="Music Therapist">Music Therapist</option>
<option value="Phlebotomist">Phlebotomist</option>
<option value="Radiologist">Radiologist</option>
<option value="Respiratory Therapist">Respiratory Therapist</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifLAW" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_LawRole">
<option style="display: none;" value=""></option>
<option value="Law Student">Law Student</option>
<option value="Attorney">Attorney</option>
<option value="Guardian ad litem">Guardian ad litem</option>
<option value="Judge">Judge</option>
</select></div>
</div>
<div id="ifMH" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_MentalHealthRole">
<option style="display: none;" value=""></option>
<option value="Case worker">Case worker</option>
<option value="Clinician/Therapist/Counselor">Clinician/Therapist/Counselor</option>
<option value="Community Support Specialist">Community Support Specialist</option>
<option value="Provisional Clinician/Therapist/Counselor">Provisional Clinician/Therapist/Counselor</option>
<option value="Other">Other</option>
</select></div>
<br><br> Behavioral Credentials <br>
<div class="select_container"><select name="_BehavioralCredentials">
<option style="display: none;" value=""></option>
<option value="BCaBA">BCaBA</option>
<option value="BCBA">BCBA</option>
<option value="BCBA-D">BCBA-D</option>
<option value="LBA">LBA</option>
<option value="LABA">LABA</option>
<option value="Other">Other</option>
<option value="None">None</option>
</select></div>
<br><br> Counseling or Therapy Credentials <br>
<div class="select_container"><select name="_CounselingorTherapyCredentials">
<option style="display: none;" value=""></option>
<option value="LPC">LPC</option>
<option value="LPCC">LPCC</option>
<option value="PLPC">PLPC</option>
<option value="LCMFT">LCMFT</option>
<option value="LMFT">LMFT</option>
<option value="Other">Other</option>
<option value="None">None</option>
</select></div>
<br><br> Social Work Credentials <br>
<div class="select_container"><select name="_SocialWorkCredentials">
<option style="display: none;" value=""></option>
<option value="LAMSW">LAMSW</option>
<option value="LBSW">LBSW</option>
<option value="LCSW">LCSW</option>
<option value="LMSW">LMSW</option>
<option value="Other">Other</option>
<option value="None">None</option>
</select></div>
<br><br> Certifications or Licenses in Substance Abuse and Addiction Credentials <input name="_SubstanceAbuseandAddictionCredentials" type="text" style="width: 100%;">
<br>
</div>
<div id="ifNCH" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_NonClinicalHealthRole">
<option style="display: none;" value=""></option>
<option value="Biostatistician">Biostatistician</option>
<option value="Quality Assurance/Compliance">Quality Assurance/Compliance</option>
<option value="Researcher/Analyst">Researcher/Analyst</option>
<option value="Other">Other</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_NonClinicalHealthPublicHealthResearchCredentials">
<option style="display: none;" value=""></option>
<option value="BME">BME</option>
<option value="CCRC">CCRC</option>
<option value="CEHT">CEHT</option>
<option value="CHC">CHC</option>
<option value="CHCP">CHCP</option>
<option value="CHES">CHES</option>
<option value="CPHQ">CPHQ</option>
<option value="CPHRM">CPHRM</option>
<option value="MCHES">MCHES</option>
<option value="PCMH CCE">PCMH CCE</option>
<option value="REHS">REHS</option>
<option value="REHS/RS">REHS/RS</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifN" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_NursingRole">
<option style="display: none;" value=""></option>
<option value="Nurse">Nurse</option>
<option value="Nurse Aide">Nurse Aide</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_NursingCredentials">
<option style="display: none;" value=""></option>
<option value="CNA">CNA</option>
<option value="LPN">LPN</option>
<option value="LVN">LVN</option>
<option value="RN">RN</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifNP" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_NursePractitionerRole">
<option style="display: none;" value=""></option>
<option value="Family Medicine">Family Medicine</option>
<option value="Internal Medicine - General">Internal Medicine - General</option>
<option value="Internal Medicine-Pediatrics (Med-Peds)">Internal Medicine-Pediatrics (Med-Peds)</option>
<option value="Internal Medicine - Specialist">Internal Medicine - Specialist</option>
<option value="Neurology">Neurology</option>
<option value="Nurse Practitioner">Nurse Practitioner</option>
<option value="Pediatrics - General">Pediatrics - General</option>
<option value="Pediatrics - Specialist">Pediatrics - Specialist</option>
<option value="Psychiatry - General">Psychiatry - General</option>
<option value="Psychiatry - Child and Adolescent">Psychiatry - Child and Adolescent</option>
<option value="Physician Assistant">Physician Assistant</option>
<option value="Other">Other</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_NursePractitionerCredentials">
<option style="display: none;" value=""></option>
<option value="ACCNS">ACCNS</option>
<option value="ANP">ANP</option>
<option value="APN">APN</option>
<option value="APRN">APRN</option>
<option value="APRN-BC">APRN-BC</option>
<option value="BC FNP">BC FNP</option>
<option value="C-FNP">C-FNP</option>
<option value="CNL">CNL</option>
<option value="CNS">CNS</option>
<option value="CPNP/CPNP-PC">CPNP/CPNP-PC</option>
<option value="CS">CS</option>
<option value="FNP/FNP-BC/FNP-C">FNP/FNP-BC/FNP-C</option>
<option value="NP/NP-C">NP/NP-C</option>
<option value="PA-C">PA-C</option>
<option value="P/MHNP/PHNP-CNS/PMHNP-BC">P/MHNP/PHNP-CNS/PMHNP-BC</option>
<option value="PMHS">PMHS</option>
<option value="PNP/PNP-BC/RNC-FNP">PNP/PNP-BC/RNC-FNP</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifOH" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_OralHealthRole">
<option style="display: none;" value=""></option>
<option value="Dentist">Dentist</option>
<option value="Dental Hygienist">Dental Hygienist</option>
<option value="Dental Assistant">Dental Assistant</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="Oral Health Credentials">
<option style="display: none;" value=""></option>
<option value="RDH">RDH</option>
<option value="DDS">DDS</option>
<option value="DMD">DMD</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifP" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_PharmacyRole">
<option style="display: none;" value=""></option>
<option value="Pharmacist">Pharmacist</option>
<option value="Pharmacy Technician">Pharmacy Technician</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_PharmacyCredentials">
<option style="display: none;" value=""></option>
<option value="AAHIVP">AAHIVP</option>
<option value="BCACP">BCACP</option>
<option value="BCPP">BCPP</option>
<option value="BCPS">BCPS</option>
<option value="CPhT">CPhT</option>
<option value="CSP">CSP</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifPHY" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_PhysicianPARole">
<option style="display: none;" value=""></option>
<option value="Family Medicine">Family Medicine</option>
<option value="Internal Medicine - General">Internal Medicine - General</option>
<option value="Internal Medicine-Pediatrics (Med-Peds)">Internal Medicine-Pediatrics (Med-Peds)</option>
<option value="Internal Medicine - Specialist">Internal Medicine - Specialist</option>
<option value="Neurology">Neurology</option>
<option value="Nurse Practitioner">Nurse Practitioner</option>
<option value="Pediatrics - General">Pediatrics - General</option>
<option value="Pediatrics - Specialist">Pediatrics - Specialist</option>
<option value="Psychiatry - General">Psychiatry - General</option>
<option value="Psychiatry - Child and Adolescent">Psychiatry - Child and Adolescent</option>
<option value="Other">Other</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_PhysicianPACredentials">
<option style="display: none;" value=""></option>
<option value="BCFM">BCFM</option>
<option value="FAAFP">FAAFP</option>
<option value="FAAP">FAAP</option>
<option value="FACS">FACS</option>
<option value="FAPA">FAPA</option>
<option value="DO">DO</option>
<option value="MBBS">MBBS</option>
<option value="MBchB">MBchB</option>
<option value="MD">MD</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifPHYA" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_PARole">
<option style="display: none;" value=""></option>
<option value="Family Medicine">Family Medicine</option>
<option value="Internal Medicine - General">Internal Medicine - General</option>
<option value="Internal Medicine-Pediatrics (Med-Peds)">Internal Medicine-Pediatrics (Med-Peds)</option>
<option value="Internal Medicine - Specialist">Internal Medicine - Specialist</option>
<option value="Neurology">Neurology</option>
<option value="Nurse Practitioner">Nurse Practitioner</option>
<option value="Pediatrics - General">Pediatrics - General</option>
<option value="Pediatrics - Specialist">Pediatrics - Specialist</option>
<option value="Psychiatry - General">Psychiatry - General</option>
<option value="Psychiatry - Child and Adolescent">Psychiatry - Child and Adolescent</option>
<option value="Other">Other</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_PACredentials">
<option style="display: none;" value=""></option>
<option value="PA">PA</option>
<option value="PA-C">PA-C</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifPSY" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_PsychologistRole">
<option style="display: none;" value=""></option>
<option value="Psychology - Clinical">Psychology - Clinical</option>
<option value="Psychology - Counseling">Psychology - Counseling</option>
<option value="Psychology - Neuro">Psychology - Neuro</option>
<option value="Psychology - School">Psychology - School</option>
<option value="Other">Other</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_PsychologyCredentials">
<option style="display: none;" value=""></option>
<option value="ABCN">ABCN</option>
<option value="ABPP">ABPP</option>
<option value="LP">LP</option>
<option value="LPA">LPA</option>
<option value="LSSP">LSSP</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifSW" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_SocialWorkRole">
<option style="display: none;" value=""></option>
<option value="Case Manager/Coordinator">Case Manager/Coordinator</option>
<option value="Clinician/Therapist/Counselor">Clinician/Therapist/Counselor</option>
<option value="Supervisor">Supervisor</option>
<option value="Other">Other</option>
</select></div>
<br><br> Social Work Credentials? <br>
<div class="select_container"><select name="_SocialWorkCredentials">
<option style="display: none;" value=""></option>
<option value="LAMSW">LAMSW</option>
<option value="LBSW">LBSW</option>
<option value="LCSW">LCSW</option>
<option value="LMSW">LMSW</option>
<option value="Other">Other</option>
</select></div>
<br><br> Behavioral Credentials <br>
<div class="select_container"><select name="_BehavioralCredentials">
<option style="display: none;" value=""></option>
<option value="BCaBA">BCaBA</option>
<option value="BCBA">BCBA</option>
<option value="BCBA-D">BCBA-D</option>
<option value="LBA">LBA</option>
<option value="LABA">LABA</option>
<option value="Other">Other</option>
<option value="None">None</option>
</select></div>
<br><br> Counseling or Therapy Credentials <br>
<div class="select_container"><select name="_CounselingorTherapyCredentials">
<option style="display: none;" value=""></option>
<option value="LPC">LPC</option>
<option value="LPCC">LPCC</option>
<option value="PLPC">PLPC</option>
<option value="LCMFT">LCMFT</option>
<option value="LMFT">LMFT</option>
<option value="Other">Other</option>
<option value="None">None</option>
</select></div>
<br><br>
</div>
<div id="ifS" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_StudentRole">
<option style="display: none;" value=""></option>
<option style="display: none;" value=""></option>
<option value="Intern/In-training">Intern/In-training</option>
<option value="Student - Undergraduate Study">Student - Undergraduate Study</option>
<option value="Student- Graduate Study">Student- Graduate Study</option>
<option value="Student - Post-graduate Study">Student - Post-graduate Study</option>
<option value="Student - Medical">Student - Medical</option>
<option value="Student- Medical Resident">Student- Medical Resident</option>
<option value="Other">Other</option>
</select></div>
<br><br> Area of Study? <input name="_AreaofStudy" type="text" style="width: 100%;">
<br>
</div>
<br> Highest Level of Education <br>
<div class="select_container"><select onchange="yesnoHeck(this);" name="_HighestLevelofEducation">
<option value="High School">High School</option>
<option value="Associates">Associates</option>
<option value="Bachelors">Bachelors</option>
<option value="Masters">Masters</option>
<option value="Doctorate">Doctorate</option>
</select></div>
<br>
<div id="ifA" style="display: none;">
<br> Associates <br>
<div class="select_container"><select name="_AssociatesDegree">
<option style="display: none;" value=""></option>
<option value="Associates AND">AND</option>
<option value="Associates ASN">ASN</option>
<option value="Associates AA/AAS/ADP">AA/AAS/ADP</option>
<option value="Associates Other">Other</option>
</select></div>
</div>
<div id="ifB" style="display: none;">
<br> Bachelors <br>
<div class="select_container"><select name="_BachelorsDegree">
<option style="display: none;" value=""></option>
<option value="Bachelors BA/BS">BA/BS</option>
<option value="Bachelors BS Ed">BS Ed</option>
<option value="Bachelors BSN">BSN</option>
<option value="Bachelors BSW">BSW</option>
<option value="Bachelors MBBS">MBBS</option>
<option value="Bachelors MBchB">MBchB</option>
<option value="Bachelors Other">Other</option>
</select></div>
</div>
<div id="ifM" style="display: none;">
<br> Masters <br>
<div class="select_container"><select name="_MastersDegree">
<option style="display: none;" value=""></option>
<option value="Masters MS">MS</option>
<option value="Masters MBA">MBA</option>
<option value="Masters MDiv">MDiv</option>
<option value="Masters MEd">MEd</option>
<option value="Masters MHA">MHA</option>
<option value="Masters MPA">MPA</option>
<option value="Masters MPAS">MPAS</option>
<option value="Masters MPH">MPH</option>
<option value="Masters MSMI">MSMI</option>
<option value="Masters MSN">MSN</option>
<option value="Masters MSW/MSSW">MSW/MSSW</option>
<option value="Masters MOT">MOT</option>
<option value="Masters MPT">MPT</option>
<option value="Masters Other">Other</option>
</select></div>
</div>
<div id="ifD" style="display: none;">
<br> Doctorate <br>
<div class="select_container"><select name="_DoctorateDegree">
<option style="display: none;" value=""></option>
<option value="Doctorate DPT">DPT</option>
<option value="Doctorate DO">DO</option>
<option value="Doctorate DNP">DNP</option>
<option value="Doctorate DNP-c">DNP-c</option>
<option value="Doctorate DHSc">DHSc</option>
<option value="Doctorate DrPH">DrPH</option>
<option value="Doctorate EdD">EdD</option>
<option value="Doctorate EDS">EDS</option>
<option value="Doctorate MD">MD</option>
<option value="Doctorate OTD">OTD</option>
<option value="Doctorate PhD">PhD</option>
<option value="Doctorate PsyD">PsyD</option>
<option value="Doctorate Other">Other</option>
</select></div>
</div>
<br>
<input type="submit" value="Sign Up For Free" class="sc_button_hover_slide_left">
</div>
<input type="hidden" name="pum_form_popup_id" value="5169">
</form>POST
<form method="post" action="" id="registration_form_2" name="">
<input type="hidden" name="memb_form_type" value="memb_registration">
<input type="hidden" id="_wpnonce" name="_wpnonce" value="2ddc00a26d"><input type="hidden" name="_wp_http_referer" value="/">
<input type="hidden" name="params"
value="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">
<input type="hidden" name="signature" value="89ca49e828dd5c26e7fa5786d74f148f9ff4be804c7e6bbfb3b8df55442bb0bd">
<div class="memberium-form"><br> First Name <input name="FirstName" required="required" type="text" style="width: 100%;">
<br> Last Name <input name="LastName" required="required" type="text" style="width: 100%;">
<br> Email <input name="Email" required="required" type="email" style="width: 100%;">
<br> Phone Number <input type="text" name="Phone2">
<br> Company <input type="text" required="required" name="Company">
<br> Organization address (personal address if not affiliated with an organization) <input type="text" placeholder="Street" name="Address2Street1" required="required">
<input type="text" placeholder="Apt/Suite/Other" name="Address2Street2">
<input type="text" placeholder="City" required="required" name="City2" style="width: 49%; display: inline;">
<input type="text" placeholder="State" required="required" name="State2" style="width: 49%; display: inline;">
<input type="text" placeholder="Zip" required="required" name="PostalCode2" style="width: 49%; display: inline;">
<input type="text" placeholder="Country" required="required" name="Country2" style="width: 49%; display: inline;">
<br><br> Password <input type="password" required="required" name="Password">
<br> Which of these fields best categorizes the field you work in? <div class="select_container"><select onchange="yesnoCheck(this);" name="_JobCategory">
<option value="Clinical Intervention">Clinical Intervention (ABA, OT, SLP, etc.)</option>
<option value="Community Support/ Resource Navigation/ Community Resource">Community Support/ Resource Navigation/ Community Resource</option>
<option value="Education">Education</option>
<option value="Family Advocate/Self-Advocate">Family Advocate/Self-Advocate</option>
<option value="Clinical Health/Allied Health">Clinical Health/Allied Health</option>
<option value="Law">Law</option>
<option value="Mental Health">Mental Health</option>
<option value="Non-Clinical Health/ Public Health/ Research">Non-Clinical Health/ Public Health/ Research</option>
<option value="Nursing">Nursing</option>
<option value="Nurse Practitioner">Nurse Practitioner</option>
<option value="Oral Health">Oral Health</option>
<option value="Pharmacy">Pharmacy</option>
<option value="Physician">Physician</option>
<option value="Physician Assistant">Physician Assistant</option>
<option value="Psychologist">Psychologist</option>
<option value="Social Work">Social Work</option>
<option value="Student">Student</option>
<option value="Other">Other</option>
</select></div>
<br>
<div id="ifCI" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_ClinicalInterventionRole">
<option style="display: none;" value=""></option>
<option value="Behavioral Implementer">Behavioral Implementer</option>
<option value="Behavioral Specialist">Behavioral Specialist</option>
<option value="Dietician">Dietician</option>
<option value="Occupational Therapist">Occupational Therapist</option>
<option value="Occupational Therapist Assistant">Occupational Therapist Assistant</option>
<option value="Physical Therapist">Physical Therapist</option>
<option value="Physical Therapist Assitant">Physical Therapist Assitant</option>
<option value="Speech Language Pathologist">Speech Language Pathologist</option>
<option value="Speech Language Pathologist - Assistant">Speech Language Pathologist - Assistant</option>
<option value="Other">Other</option>
</select></div><br>
<br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_ClinicalInterventionCredentials">
<option style="display: none;" value=""></option>
<option value="BCaBA">BCaBA</option>
<option value="BCBA">BCBA</option>
<option value="BCBA-D">BCBA-D</option>
<option value="LBA">LBA</option>
<option value="LABA">LABA</option>
<option value="RBT">RBT</option>
<option value="LD">LD</option>
<option value="OTR/L">OTR/L</option>
<option value="COTA/L">COTA/L</option>
<option value="PT">PT</option>
<option value="PTA">PTA</option>
<option value="CCC-SLP">CCC-SLP</option>
<option value="SLPA">SLPA</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifCS" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_CommunitySupportRole">
<option style="display: none;" value=""></option>
<option value="Certified Peer Mentor">Certified Peer Mentor</option>
<option value="Community Health Worker">Community Health Worker</option>
<option value="Family Advocate">Family Advocate</option>
<option value="Family/Caregiver/Patient Navigator">Family/Caregiver/Patient Navigator</option>
<option value="Program Coordinator/Manager/Supervisor">Program Coordinator/Manager/Supervisor</option>
<option value="Resource Specialist/Resource Navigator">Resource Specialist/Resource Navigator</option>
<option value="Support Coordinator/Service Coordinator">Support Coordinator/Service Coordinator</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifEDUCATION" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_EducationRole">
<option style="display: none;" value=""></option>
<option value="Certified Peer Mentor">Certified Peer Mentor</option>
<option value="Higher Education (non-medical): Professor/Assistant Prof/Associate Prof/Adjunct Prof/Emeritus, etc.">Higher Education (non-medical): Professor/Assistant Prof/Associate Prof/Adjunct Prof/Emeritus, etc.</option>
<option value="Para Professional">Para Professional</option>
<option value="School Administrator">School Administrator</option>
<option value="School Principal">School Principal</option>
<option value="School Teacher">School Teacher</option>
<option value="Other">Other</option>
</select></div>
<br><br> Please provide your credentials related to this field of work <input name="_EducationCredentials" type="text" style="width: 100%;">
<br>
</div>
<div id="ifFA" style="display: none;">
<br> Please select if you have lived experience in the following areas: <br>
<div class="select_container"><select name="_FASALivedExperience">
<option style="display: none;" value=""></option>
<option value="Parent or caregiver of a child or person with autism or other developmental or intellectual disability">Parent or caregiver of a child or person with autism or other developmental or intellectual disability</option>
<option value="Person with autism/ Autistic person">Person with autism/ Autistic person</option>
</select></div>
<br><br> What is your role in that field? <br>
<div class="select_container"><select name="_FASARole">
<option style="display: none;" value=""></option>
<option value="Caregiver">Caregiver</option>
<option value="Certified Peer Mentor">Certified Peer Mentor</option>
<option value="Extended Family / Caregiver Support">Extended Family / Caregiver Support</option>
<option value="Family Advocate">Family Advocate</option>
<option value="Foster Parent">Foster Parent</option>
<option value="Grandparent">Grandparent</option>
<option value="Guardian">Guardian</option>
<option value="Kinship Foster Parent">Kinship Foster Parent</option>
<option value="Parent">Parent</option>
<option value="Parent Partner">Parent Partner</option>
<option value="Self-Advocate">Self-Advocate</option>
<option value="Other">Other</option>
<option value="Guardian">None</option>
</select></div>
</div>
<div id="ifCH" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_ClinicalHealthRole">
<option style="display: none;" value=""></option>
<option value="Clinical Lab Worker/ Med Technologist">Clinical Lab Worker/ Med Technologist</option>
<option value="Electroneurodiagnostic Technologist">Electroneurodiagnostic Technologist</option>
<option value="EMT/ Paramedic">EMT/ Paramedic</option>
<option value="Exercise Science Professional (trainer, physiologist)">Exercise Science Professional (trainer, physiologist)</option>
<option value="Genetic Counselor/Genetic Assistants">Genetic Counselor/Genetic Assistants</option>
<option value="Kinesiotherapist">Kinesiotherapist</option>
<option value="Lactation Consultant">Lactation Consultant</option>
<option value="Magnetic Resonance Technologist (MRI)">Magnetic Resonance Technologist (MRI)</option>
<option value="Medical Assistant">Medical Assistant</option>
<option value="Music Therapist">Music Therapist</option>
<option value="Phlebotomist">Phlebotomist</option>
<option value="Radiologist">Radiologist</option>
<option value="Respiratory Therapist">Respiratory Therapist</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifLAW" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_LawRole">
<option style="display: none;" value=""></option>
<option value="Law Student">Law Student</option>
<option value="Attorney">Attorney</option>
<option value="Guardian ad litem">Guardian ad litem</option>
<option value="Judge">Judge</option>
</select></div>
</div>
<div id="ifMH" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_MentalHealthRole">
<option style="display: none;" value=""></option>
<option value="Case worker">Case worker</option>
<option value="Clinician/Therapist/Counselor">Clinician/Therapist/Counselor</option>
<option value="Community Support Specialist">Community Support Specialist</option>
<option value="Provisional Clinician/Therapist/Counselor">Provisional Clinician/Therapist/Counselor</option>
<option value="Other">Other</option>
</select></div>
<br><br> Behavioral Credentials <br>
<div class="select_container"><select name="_BehavioralCredentials">
<option style="display: none;" value=""></option>
<option value="BCaBA">BCaBA</option>
<option value="BCBA">BCBA</option>
<option value="BCBA-D">BCBA-D</option>
<option value="LBA">LBA</option>
<option value="LABA">LABA</option>
<option value="Other">Other</option>
<option value="None">None</option>
</select></div>
<br><br> Counseling or Therapy Credentials <br>
<div class="select_container"><select name="_CounselingorTherapyCredentials">
<option style="display: none;" value=""></option>
<option value="LPC">LPC</option>
<option value="LPCC">LPCC</option>
<option value="PLPC">PLPC</option>
<option value="LCMFT">LCMFT</option>
<option value="LMFT">LMFT</option>
<option value="Other">Other</option>
<option value="None">None</option>
</select></div>
<br><br> Social Work Credentials <br>
<div class="select_container"><select name="_SocialWorkCredentials">
<option style="display: none;" value=""></option>
<option value="LAMSW">LAMSW</option>
<option value="LBSW">LBSW</option>
<option value="LCSW">LCSW</option>
<option value="LMSW">LMSW</option>
<option value="Other">Other</option>
<option value="None">None</option>
</select></div>
<br><br> Certifications or Licenses in Substance Abuse and Addiction Credentials <input name="_SubstanceAbuseandAddictionCredentials" type="text" style="width: 100%;">
<br>
</div>
<div id="ifNCH" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_NonClinicalHealthRole">
<option style="display: none;" value=""></option>
<option value="Biostatistician">Biostatistician</option>
<option value="Quality Assurance/Compliance">Quality Assurance/Compliance</option>
<option value="Researcher/Analyst">Researcher/Analyst</option>
<option value="Other">Other</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_NonClinicalHealthPublicHealthResearchCredentials">
<option style="display: none;" value=""></option>
<option value="BME">BME</option>
<option value="CCRC">CCRC</option>
<option value="CEHT">CEHT</option>
<option value="CHC">CHC</option>
<option value="CHCP">CHCP</option>
<option value="CHES">CHES</option>
<option value="CPHQ">CPHQ</option>
<option value="CPHRM">CPHRM</option>
<option value="MCHES">MCHES</option>
<option value="PCMH CCE">PCMH CCE</option>
<option value="REHS">REHS</option>
<option value="REHS/RS">REHS/RS</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifN" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_NursingRole">
<option style="display: none;" value=""></option>
<option value="Nurse">Nurse</option>
<option value="Nurse Aide">Nurse Aide</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_NursingCredentials">
<option style="display: none;" value=""></option>
<option value="CNA">CNA</option>
<option value="LPN">LPN</option>
<option value="LVN">LVN</option>
<option value="RN">RN</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifNP" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_NursePractitionerRole">
<option style="display: none;" value=""></option>
<option value="Family Medicine">Family Medicine</option>
<option value="Internal Medicine - General">Internal Medicine - General</option>
<option value="Internal Medicine-Pediatrics (Med-Peds)">Internal Medicine-Pediatrics (Med-Peds)</option>
<option value="Internal Medicine - Specialist">Internal Medicine - Specialist</option>
<option value="Neurology">Neurology</option>
<option value="Nurse Practitioner">Nurse Practitioner</option>
<option value="Pediatrics - General">Pediatrics - General</option>
<option value="Pediatrics - Specialist">Pediatrics - Specialist</option>
<option value="Psychiatry - General">Psychiatry - General</option>
<option value="Psychiatry - Child and Adolescent">Psychiatry - Child and Adolescent</option>
<option value="Physician Assistant">Physician Assistant</option>
<option value="Other">Other</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_NursePractitionerCredentials">
<option style="display: none;" value=""></option>
<option value="ACCNS">ACCNS</option>
<option value="ANP">ANP</option>
<option value="APN">APN</option>
<option value="APRN">APRN</option>
<option value="APRN-BC">APRN-BC</option>
<option value="BC FNP">BC FNP</option>
<option value="C-FNP">C-FNP</option>
<option value="CNL">CNL</option>
<option value="CNS">CNS</option>
<option value="CPNP/CPNP-PC">CPNP/CPNP-PC</option>
<option value="CS">CS</option>
<option value="FNP/FNP-BC/FNP-C">FNP/FNP-BC/FNP-C</option>
<option value="NP/NP-C">NP/NP-C</option>
<option value="PA-C">PA-C</option>
<option value="P/MHNP/PHNP-CNS/PMHNP-BC">P/MHNP/PHNP-CNS/PMHNP-BC</option>
<option value="PMHS">PMHS</option>
<option value="PNP/PNP-BC/RNC-FNP">PNP/PNP-BC/RNC-FNP</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifOH" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_OralHealthRole">
<option style="display: none;" value=""></option>
<option value="Dentist">Dentist</option>
<option value="Dental Hygienist">Dental Hygienist</option>
<option value="Dental Assistant">Dental Assistant</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="Oral Health Credentials">
<option style="display: none;" value=""></option>
<option value="RDH">RDH</option>
<option value="DDS">DDS</option>
<option value="DMD">DMD</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifP" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_PharmacyRole">
<option style="display: none;" value=""></option>
<option value="Pharmacist">Pharmacist</option>
<option value="Pharmacy Technician">Pharmacy Technician</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_PharmacyCredentials">
<option style="display: none;" value=""></option>
<option value="AAHIVP">AAHIVP</option>
<option value="BCACP">BCACP</option>
<option value="BCPP">BCPP</option>
<option value="BCPS">BCPS</option>
<option value="CPhT">CPhT</option>
<option value="CSP">CSP</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifPHY" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_PhysicianPARole">
<option style="display: none;" value=""></option>
<option value="Family Medicine">Family Medicine</option>
<option value="Internal Medicine - General">Internal Medicine - General</option>
<option value="Internal Medicine-Pediatrics (Med-Peds)">Internal Medicine-Pediatrics (Med-Peds)</option>
<option value="Internal Medicine - Specialist">Internal Medicine - Specialist</option>
<option value="Neurology">Neurology</option>
<option value="Nurse Practitioner">Nurse Practitioner</option>
<option value="Pediatrics - General">Pediatrics - General</option>
<option value="Pediatrics - Specialist">Pediatrics - Specialist</option>
<option value="Psychiatry - General">Psychiatry - General</option>
<option value="Psychiatry - Child and Adolescent">Psychiatry - Child and Adolescent</option>
<option value="Other">Other</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_PhysicianPACredentials">
<option style="display: none;" value=""></option>
<option value="BCFM">BCFM</option>
<option value="FAAFP">FAAFP</option>
<option value="FAAP">FAAP</option>
<option value="FACS">FACS</option>
<option value="FAPA">FAPA</option>
<option value="DO">DO</option>
<option value="MBBS">MBBS</option>
<option value="MBchB">MBchB</option>
<option value="MD">MD</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifPHYA" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_PARole">
<option style="display: none;" value=""></option>
<option value="Family Medicine">Family Medicine</option>
<option value="Internal Medicine - General">Internal Medicine - General</option>
<option value="Internal Medicine-Pediatrics (Med-Peds)">Internal Medicine-Pediatrics (Med-Peds)</option>
<option value="Internal Medicine - Specialist">Internal Medicine - Specialist</option>
<option value="Neurology">Neurology</option>
<option value="Nurse Practitioner">Nurse Practitioner</option>
<option value="Pediatrics - General">Pediatrics - General</option>
<option value="Pediatrics - Specialist">Pediatrics - Specialist</option>
<option value="Psychiatry - General">Psychiatry - General</option>
<option value="Psychiatry - Child and Adolescent">Psychiatry - Child and Adolescent</option>
<option value="Other">Other</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_PACredentials">
<option style="display: none;" value=""></option>
<option value="PA">PA</option>
<option value="PA-C">PA-C</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifPSY" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_PsychologistRole">
<option style="display: none;" value=""></option>
<option value="Psychology - Clinical">Psychology - Clinical</option>
<option value="Psychology - Counseling">Psychology - Counseling</option>
<option value="Psychology - Neuro">Psychology - Neuro</option>
<option value="Psychology - School">Psychology - School</option>
<option value="Other">Other</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_PsychologyCredentials">
<option style="display: none;" value=""></option>
<option value="ABCN">ABCN</option>
<option value="ABPP">ABPP</option>
<option value="LP">LP</option>
<option value="LPA">LPA</option>
<option value="LSSP">LSSP</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifSW" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_SocialWorkRole">
<option style="display: none;" value=""></option>
<option value="Case Manager/Coordinator">Case Manager/Coordinator</option>
<option value="Clinician/Therapist/Counselor">Clinician/Therapist/Counselor</option>
<option value="Supervisor">Supervisor</option>
<option value="Other">Other</option>
</select></div>
<br><br> Social Work Credentials? <br>
<div class="select_container"><select name="_SocialWorkCredentials">
<option style="display: none;" value=""></option>
<option value="LAMSW">LAMSW</option>
<option value="LBSW">LBSW</option>
<option value="LCSW">LCSW</option>
<option value="LMSW">LMSW</option>
<option value="Other">Other</option>
</select></div>
<br><br> Behavioral Credentials <br>
<div class="select_container"><select name="_BehavioralCredentials">
<option style="display: none;" value=""></option>
<option value="BCaBA">BCaBA</option>
<option value="BCBA">BCBA</option>
<option value="BCBA-D">BCBA-D</option>
<option value="LBA">LBA</option>
<option value="LABA">LABA</option>
<option value="Other">Other</option>
<option value="None">None</option>
</select></div>
<br><br> Counseling or Therapy Credentials <br>
<div class="select_container"><select name="_CounselingorTherapyCredentials">
<option style="display: none;" value=""></option>
<option value="LPC">LPC</option>
<option value="LPCC">LPCC</option>
<option value="PLPC">PLPC</option>
<option value="LCMFT">LCMFT</option>
<option value="LMFT">LMFT</option>
<option value="Other">Other</option>
<option value="None">None</option>
</select></div>
<br><br>
</div>
<div id="ifS" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_StudentRole">
<option style="display: none;" value=""></option>
<option style="display: none;" value=""></option>
<option value="Intern/In-training">Intern/In-training</option>
<option value="Student - Undergraduate Study">Student - Undergraduate Study</option>
<option value="Student- Graduate Study">Student- Graduate Study</option>
<option value="Student - Post-graduate Study">Student - Post-graduate Study</option>
<option value="Student - Medical">Student - Medical</option>
<option value="Student- Medical Resident">Student- Medical Resident</option>
<option value="Other">Other</option>
</select></div>
<br><br> Area of Study? <input name="_AreaofStudy" type="text" style="width: 100%;">
<br>
</div>
<br> Highest Level of Education <br>
<div class="select_container"><select onchange="yesnoHeck(this);" name="_HighestLevelofEducation">
<option value="High School">High School</option>
<option value="Associates">Associates</option>
<option value="Bachelors">Bachelors</option>
<option value="Masters">Masters</option>
<option value="Doctorate">Doctorate</option>
</select></div>
<br>
<div id="ifA" style="display: none;">
<br> Associates <br>
<div class="select_container"><select name="_AssociatesDegree">
<option style="display: none;" value=""></option>
<option value="Associates AND">AND</option>
<option value="Associates ASN">ASN</option>
<option value="Associates AA/AAS/ADP">AA/AAS/ADP</option>
<option value="Associates Other">Other</option>
</select></div>
</div>
<div id="ifB" style="display: none;">
<br> Bachelors <br>
<div class="select_container"><select name="_BachelorsDegree">
<option style="display: none;" value=""></option>
<option value="Bachelors BA/BS">BA/BS</option>
<option value="Bachelors BS Ed">BS Ed</option>
<option value="Bachelors BSN">BSN</option>
<option value="Bachelors BSW">BSW</option>
<option value="Bachelors MBBS">MBBS</option>
<option value="Bachelors MBchB">MBchB</option>
<option value="Bachelors Other">Other</option>
</select></div>
</div>
<div id="ifM" style="display: none;">
<br> Masters <br>
<div class="select_container"><select name="_MastersDegree">
<option style="display: none;" value=""></option>
<option value="Masters MS">MS</option>
<option value="Masters MBA">MBA</option>
<option value="Masters MDiv">MDiv</option>
<option value="Masters MEd">MEd</option>
<option value="Masters MHA">MHA</option>
<option value="Masters MPA">MPA</option>
<option value="Masters MPAS">MPAS</option>
<option value="Masters MPH">MPH</option>
<option value="Masters MSMI">MSMI</option>
<option value="Masters MSN">MSN</option>
<option value="Masters MSW/MSSW">MSW/MSSW</option>
<option value="Masters MOT">MOT</option>
<option value="Masters MPT">MPT</option>
<option value="Masters Other">Other</option>
</select></div>
</div>
<div id="ifD" style="display: none;">
<br> Doctorate <br>
<div class="select_container"><select name="_DoctorateDegree">
<option style="display: none;" value=""></option>
<option value="Doctorate DPT">DPT</option>
<option value="Doctorate DO">DO</option>
<option value="Doctorate DNP">DNP</option>
<option value="Doctorate DNP-c">DNP-c</option>
<option value="Doctorate DHSc">DHSc</option>
<option value="Doctorate DrPH">DrPH</option>
<option value="Doctorate EdD">EdD</option>
<option value="Doctorate EDS">EDS</option>
<option value="Doctorate MD">MD</option>
<option value="Doctorate OTD">OTD</option>
<option value="Doctorate PhD">PhD</option>
<option value="Doctorate PsyD">PsyD</option>
<option value="Doctorate Other">Other</option>
</select></div>
</div>
<br>
<input type="submit" value="Sign Up For Free" class="sc_button_hover_slide_left">
</div>
<input type="hidden" name="pum_form_popup_id" value="4921">
</form>POST
<form method="post" action="" id="registration_form_3" name="">
<input type="hidden" name="memb_form_type" value="memb_registration">
<input type="hidden" id="_wpnonce" name="_wpnonce" value="cf852cbe42"><input type="hidden" name="_wp_http_referer" value="/">
<input type="hidden" name="params"
value="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">
<input type="hidden" name="signature" value="25374c9b4f6e5693630da9d5a109605fee7fdc4a5eaac4c9af5095c89dfa79fa">
<div class="memberium-form" style="font-weight: 600!important;"><br> First Name <input name="FirstName" required="required" type="text" style="width: 100%;">
<br> Last Name <input name="LastName" required="required" type="text" style="width: 100%;">
<br> Email <input name="Email" required="required" type="email" style="width: 100%;">
<br> Phone Number <input type="text" name="Phone2">
<br> Company <input type="text" required="required" name="Company">
<br> Organization address (personal address if not affiliated with an organization) <input type="text" placeholder="Street" name="Address2Street1" required="required">
<input type="text" placeholder="Apt/Suite/Other" name="Address2Street2">
<input type="text" placeholder="City" required="required" name="City2" style="width: 49%; display: inline;">
<input type="text" placeholder="State" required="required" name="State2" style="width: 49%; display: inline;">
<input type="text" placeholder="Zip" required="required" name="PostalCode2" style="width: 49%; display: inline;">
<input type="text" placeholder="Country" required="required" name="Country2" style="width: 49%; display: inline;">
<br><br> Password <input name="Password" required="required" type="password">
<br> Which of these fields best categorizes the field you work in? <div class="select_container"><select onchange="yesnoCheck(this);" name="_JobCategory">
<option value="Clinical Intervention">Clinical Intervention (ABA, OT, SLP, etc.)</option>
<option value="Community Support/ Resource Navigation/ Community Resource">Community Support/ Resource Navigation/ Community Resource</option>
<option value="Education">Education</option>
<option value="Family Advocate/Self-Advocate">Family Advocate/Self-Advocate</option>
<option value="Clinical Health/Allied Health">Clinical Health/Allied Health</option>
<option value="Law">Law</option>
<option value="Mental Health">Mental Health</option>
<option value="Non-Clinical Health/ Public Health/ Research">Non-Clinical Health/ Public Health/ Research</option>
<option value="Nursing">Nursing</option>
<option value="Nurse Practitioner">Nurse Practitioner</option>
<option value="Oral Health">Oral Health</option>
<option value="Pharmacy">Pharmacy</option>
<option value="Physician">Physician</option>
<option value="Physician Assistant">Physician Assistant</option>
<option value="Psychologist">Psychologist</option>
<option value="Social Work">Social Work</option>
<option value="Student">Student</option>
<option value="Other">Other</option>
</select></div>
<br>
<div id="ifCI" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_ClinicalInterventionRole">
<option style="display: none;" value=""></option>
<option value="Behavioral Implementer">Behavioral Implementer</option>
<option value="Behavioral Specialist">Behavioral Specialist</option>
<option value="Dietician">Dietician</option>
<option value="Occupational Therapist">Occupational Therapist</option>
<option value="Occupational Therapist Assistant">Occupational Therapist Assistant</option>
<option value="Physical Therapist">Physical Therapist</option>
<option value="Physical Therapist Assitant">Physical Therapist Assitant</option>
<option value="Speech Language Pathologist">Speech Language Pathologist</option>
<option value="Speech Language Pathologist - Assistant">Speech Language Pathologist - Assistant</option>
<option value="Other">Other</option>
</select></div><br>
<br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_ClinicalInterventionCredentials">
<option style="display: none;" value=""></option>
<option value="BCaBA">BCaBA</option>
<option value="BCBA">BCBA</option>
<option value="BCBA-D">BCBA-D</option>
<option value="LBA">LBA</option>
<option value="LABA">LABA</option>
<option value="RBT">RBT</option>
<option value="LD">LD</option>
<option value="OTR/L">OTR/L</option>
<option value="COTA/L">COTA/L</option>
<option value="PT">PT</option>
<option value="PTA">PTA</option>
<option value="CCC-SLP">CCC-SLP</option>
<option value="SLPA">SLPA</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifCS" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_CommunitySupportRole">
<option style="display: none;" value=""></option>
<option value="Certified Peer Mentor">Certified Peer Mentor</option>
<option value="Community Health Worker">Community Health Worker</option>
<option value="Family Advocate">Family Advocate</option>
<option value="Family/Caregiver/Patient Navigator">Family/Caregiver/Patient Navigator</option>
<option value="Program Coordinator/Manager/Supervisor">Program Coordinator/Manager/Supervisor</option>
<option value="Resource Specialist/Resource Navigator">Resource Specialist/Resource Navigator</option>
<option value="Support Coordinator/Service Coordinator">Support Coordinator/Service Coordinator</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifEDUCATION" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_EducationRole">
<option style="display: none;" value=""></option>
<option value="Certified Peer Mentor">Certified Peer Mentor</option>
<option value="Higher Education (non-medical): Professor/Assistant Prof/Associate Prof/Adjunct Prof/Emeritus, etc.">Higher Education (non-medical): Professor/Assistant Prof/Associate Prof/Adjunct Prof/Emeritus, etc.</option>
<option value="Para Professional">Para Professional</option>
<option value="School Administrator">School Administrator</option>
<option value="School Principal">School Principal</option>
<option value="School Teacher">School Teacher</option>
<option value="Other">Other</option>
</select></div>
<br><br> Please provide your credentials related to this field of work <input name="_EducationCredentials" type="text" style="width: 100%;">
<br>
</div>
<div id="ifFA" style="display: none;">
<br> Please select if you have lived experience in the following areas: <br>
<div class="select_container"><select name="_FASALivedExperience">
<option style="display: none;" value=""></option>
<option value="Parent or caregiver of a child or person with autism or other developmental or intellectual disability">Parent or caregiver of a child or person with autism or other developmental or intellectual disability</option>
<option value="Person with autism/ Autistic person">Person with autism/ Autistic person</option>
</select></div>
<br><br> What is your role in that field? <br>
<div class="select_container"><select name="_FASARole">
<option style="display: none;" value=""></option>
<option value="Caregiver">Caregiver</option>
<option value="Certified Peer Mentor">Certified Peer Mentor</option>
<option value="Extended Family / Caregiver Support">Extended Family / Caregiver Support</option>
<option value="Family Advocate">Family Advocate</option>
<option value="Foster Parent">Foster Parent</option>
<option value="Grandparent">Grandparent</option>
<option value="Guardian">Guardian</option>
<option value="Kinship Foster Parent">Kinship Foster Parent</option>
<option value="Parent">Parent</option>
<option value="Parent Partner">Parent Partner</option>
<option value="Self-Advocate">Self-Advocate</option>
<option value="Other">Other</option>
<option value="Guardian">None</option>
</select></div>
</div>
<div id="ifCH" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_ClinicalHealthRole">
<option style="display: none;" value=""></option>
<option value="Clinical Lab Worker/ Med Technologist">Clinical Lab Worker/ Med Technologist</option>
<option value="Electroneurodiagnostic Technologist">Electroneurodiagnostic Technologist</option>
<option value="EMT/ Paramedic">EMT/ Paramedic</option>
<option value="Exercise Science Professional (trainer, physiologist)">Exercise Science Professional (trainer, physiologist)</option>
<option value="Genetic Counselor/Genetic Assistants">Genetic Counselor/Genetic Assistants</option>
<option value="Kinesiotherapist">Kinesiotherapist</option>
<option value="Lactation Consultant">Lactation Consultant</option>
<option value="Magnetic Resonance Technologist (MRI)">Magnetic Resonance Technologist (MRI)</option>
<option value="Medical Assistant">Medical Assistant</option>
<option value="Music Therapist">Music Therapist</option>
<option value="Phlebotomist">Phlebotomist</option>
<option value="Radiologist">Radiologist</option>
<option value="Respiratory Therapist">Respiratory Therapist</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifLAW" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_LawRole">
<option style="display: none;" value=""></option>
<option value="Law Student">Law Student</option>
<option value="Attorney">Attorney</option>
<option value="Guardian ad litem">Guardian ad litem</option>
<option value="Judge">Judge</option>
</select></div>
</div>
<div id="ifMH" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_MentalHealthRole">
<option style="display: none;" value=""></option>
<option value="Case worker">Case worker</option>
<option value="Clinician/Therapist/Counselor">Clinician/Therapist/Counselor</option>
<option value="Community Support Specialist">Community Support Specialist</option>
<option value="Provisional Clinician/Therapist/Counselor">Provisional Clinician/Therapist/Counselor</option>
<option value="Other">Other</option>
</select></div>
<br><br> Behavioral Credentials <br>
<div class="select_container"><select name="_BehavioralCredentials">
<option style="display: none;" value=""></option>
<option value="BCaBA">BCaBA</option>
<option value="BCBA">BCBA</option>
<option value="BCBA-D">BCBA-D</option>
<option value="LBA">LBA</option>
<option value="LABA">LABA</option>
<option value="Other">Other</option>
<option value="None">None</option>
</select></div>
<br><br> Counseling or Therapy Credentials <br>
<div class="select_container"><select name="_CounselingorTherapyCredentials">
<option style="display: none;" value=""></option>
<option value="LPC">LPC</option>
<option value="LPCC">LPCC</option>
<option value="PLPC">PLPC</option>
<option value="LCMFT">LCMFT</option>
<option value="LMFT">LMFT</option>
<option value="Other">Other</option>
<option value="None">None</option>
</select></div>
<br><br> Social Work Credentials <br>
<div class="select_container"><select name="_SocialWorkCredentials">
<option style="display: none;" value=""></option>
<option value="LAMSW">LAMSW</option>
<option value="LBSW">LBSW</option>
<option value="LCSW">LCSW</option>
<option value="LMSW">LMSW</option>
<option value="Other">Other</option>
<option value="None">None</option>
</select></div>
<br><br> Certifications or Licenses in Substance Abuse and Addiction Credentials <input name="_SubstanceAbuseandAddictionCredentials" type="text" style="width: 100%;">
<br>
</div>
<div id="ifNCH" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_NonClinicalHealthRole">
<option style="display: none;" value=""></option>
<option value="Biostatistician">Biostatistician</option>
<option value="Quality Assurance/Compliance">Quality Assurance/Compliance</option>
<option value="Researcher/Analyst">Researcher/Analyst</option>
<option value="Other">Other</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_NonClinicalHealthPublicHealthResearchCredentials">
<option style="display: none;" value=""></option>
<option value="BME">BME</option>
<option value="CCRC">CCRC</option>
<option value="CEHT">CEHT</option>
<option value="CHC">CHC</option>
<option value="CHCP">CHCP</option>
<option value="CHES">CHES</option>
<option value="CPHQ">CPHQ</option>
<option value="CPHRM">CPHRM</option>
<option value="MCHES">MCHES</option>
<option value="PCMH CCE">PCMH CCE</option>
<option value="REHS">REHS</option>
<option value="REHS/RS">REHS/RS</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifN" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_NursingRole">
<option style="display: none;" value=""></option>
<option value="Nurse">Nurse</option>
<option value="Nurse Aide">Nurse Aide</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_NursingCredentials">
<option style="display: none;" value=""></option>
<option value="CNA">CNA</option>
<option value="LPN">LPN</option>
<option value="LVN">LVN</option>
<option value="RN">RN</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifNP" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_NursePractitionerRole">
<option style="display: none;" value=""></option>
<option value="Family Medicine">Family Medicine</option>
<option value="Internal Medicine - General">Internal Medicine - General</option>
<option value="Internal Medicine-Pediatrics (Med-Peds)">Internal Medicine-Pediatrics (Med-Peds)</option>
<option value="Internal Medicine - Specialist">Internal Medicine - Specialist</option>
<option value="Neurology">Neurology</option>
<option value="Nurse Practitioner">Nurse Practitioner</option>
<option value="Pediatrics - General">Pediatrics - General</option>
<option value="Pediatrics - Specialist">Pediatrics - Specialist</option>
<option value="Psychiatry - General">Psychiatry - General</option>
<option value="Psychiatry - Child and Adolescent">Psychiatry - Child and Adolescent</option>
<option value="Physician Assistant">Physician Assistant</option>
<option value="Other">Other</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_NursePractitionerCredentials">
<option style="display: none;" value=""></option>
<option value="ACCNS">ACCNS</option>
<option value="ANP">ANP</option>
<option value="APN">APN</option>
<option value="APRN">APRN</option>
<option value="APRN-BC">APRN-BC</option>
<option value="BC FNP">BC FNP</option>
<option value="C-FNP">C-FNP</option>
<option value="CNL">CNL</option>
<option value="CNS">CNS</option>
<option value="CPNP/CPNP-PC">CPNP/CPNP-PC</option>
<option value="CS">CS</option>
<option value="FNP/FNP-BC/FNP-C">FNP/FNP-BC/FNP-C</option>
<option value="NP/NP-C">NP/NP-C</option>
<option value="PA-C">PA-C</option>
<option value="P/MHNP/PHNP-CNS/PMHNP-BC">P/MHNP/PHNP-CNS/PMHNP-BC</option>
<option value="PMHS">PMHS</option>
<option value="PNP/PNP-BC/RNC-FNP">PNP/PNP-BC/RNC-FNP</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifOH" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_OralHealthRole">
<option style="display: none;" value=""></option>
<option value="Dentist">Dentist</option>
<option value="Dental Hygienist">Dental Hygienist</option>
<option value="Dental Assistant">Dental Assistant</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="Oral Health Credentials">
<option style="display: none;" value=""></option>
<option value="RDH">RDH</option>
<option value="DDS">DDS</option>
<option value="DMD">DMD</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifP" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_PharmacyRole">
<option style="display: none;" value=""></option>
<option value="Pharmacist">Pharmacist</option>
<option value="Pharmacy Technician">Pharmacy Technician</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_PharmacyCredentials">
<option style="display: none;" value=""></option>
<option value="AAHIVP">AAHIVP</option>
<option value="BCACP">BCACP</option>
<option value="BCPP">BCPP</option>
<option value="BCPS">BCPS</option>
<option value="CPhT">CPhT</option>
<option value="CSP">CSP</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifPHY" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_PhysicianPARole">
<option style="display: none;" value=""></option>
<option value="Family Medicine">Family Medicine</option>
<option value="Internal Medicine - General">Internal Medicine - General</option>
<option value="Internal Medicine-Pediatrics (Med-Peds)">Internal Medicine-Pediatrics (Med-Peds)</option>
<option value="Internal Medicine - Specialist">Internal Medicine - Specialist</option>
<option value="Neurology">Neurology</option>
<option value="Nurse Practitioner">Nurse Practitioner</option>
<option value="Pediatrics - General">Pediatrics - General</option>
<option value="Pediatrics - Specialist">Pediatrics - Specialist</option>
<option value="Psychiatry - General">Psychiatry - General</option>
<option value="Psychiatry - Child and Adolescent">Psychiatry - Child and Adolescent</option>
<option value="Other">Other</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_PhysicianPACredentials">
<option style="display: none;" value=""></option>
<option value="BCFM">BCFM</option>
<option value="FAAFP">FAAFP</option>
<option value="FAAP">FAAP</option>
<option value="FACS">FACS</option>
<option value="FAPA">FAPA</option>
<option value="DO">DO</option>
<option value="MBBS">MBBS</option>
<option value="MBchB">MBchB</option>
<option value="MD">MD</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifPHYA" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_PARole">
<option style="display: none;" value=""></option>
<option value="Family Medicine">Family Medicine</option>
<option value="Internal Medicine - General">Internal Medicine - General</option>
<option value="Internal Medicine-Pediatrics (Med-Peds)">Internal Medicine-Pediatrics (Med-Peds)</option>
<option value="Internal Medicine - Specialist">Internal Medicine - Specialist</option>
<option value="Neurology">Neurology</option>
<option value="Nurse Practitioner">Nurse Practitioner</option>
<option value="Pediatrics - General">Pediatrics - General</option>
<option value="Pediatrics - Specialist">Pediatrics - Specialist</option>
<option value="Psychiatry - General">Psychiatry - General</option>
<option value="Psychiatry - Child and Adolescent">Psychiatry - Child and Adolescent</option>
<option value="Other">Other</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_PACredentials">
<option style="display: none;" value=""></option>
<option value="PA">PA</option>
<option value="PA-C">PA-C</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifPSY" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_PsychologistRole">
<option style="display: none;" value=""></option>
<option value="Psychology - Clinical">Psychology - Clinical</option>
<option value="Psychology - Counseling">Psychology - Counseling</option>
<option value="Psychology - Neuro">Psychology - Neuro</option>
<option value="Psychology - School">Psychology - School</option>
<option value="Other">Other</option>
</select></div>
<br><br> What credentials do you have relating to your field of work? <br>
<div class="select_container"><select name="_PsychologyCredentials">
<option style="display: none;" value=""></option>
<option value="ABCN">ABCN</option>
<option value="ABPP">ABPP</option>
<option value="LP">LP</option>
<option value="LPA">LPA</option>
<option value="LSSP">LSSP</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="ifSW" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_SocialWorkRole">
<option style="display: none;" value=""></option>
<option value="Case Manager/Coordinator">Case Manager/Coordinator</option>
<option value="Clinician/Therapist/Counselor">Clinician/Therapist/Counselor</option>
<option value="Supervisor">Supervisor</option>
<option value="Other">Other</option>
</select></div>
<br><br> Social Work Credentials? <br>
<div class="select_container"><select name="_SocialWorkCredentials">
<option style="display: none;" value=""></option>
<option value="LAMSW">LAMSW</option>
<option value="LBSW">LBSW</option>
<option value="LCSW">LCSW</option>
<option value="LMSW">LMSW</option>
<option value="Other">Other</option>
</select></div>
<br><br> Behavioral Credentials <br>
<div class="select_container"><select name="_BehavioralCredentials">
<option style="display: none;" value=""></option>
<option value="BCaBA">BCaBA</option>
<option value="BCBA">BCBA</option>
<option value="BCBA-D">BCBA-D</option>
<option value="LBA">LBA</option>
<option value="LABA">LABA</option>
<option value="Other">Other</option>
<option value="None">None</option>
</select></div>
<br><br> Counseling or Therapy Credentials <br>
<div class="select_container"><select name="_CounselingorTherapyCredentials">
<option style="display: none;" value=""></option>
<option value="LPC">LPC</option>
<option value="LPCC">LPCC</option>
<option value="PLPC">PLPC</option>
<option value="LCMFT">LCMFT</option>
<option value="LMFT">LMFT</option>
<option value="Other">Other</option>
<option value="None">None</option>
</select></div>
<br><br>
</div>
<div id="ifS" style="display: none;">
<br> What is your role in that field? <br>
<div class="select_container"><select name="_StudentRole">
<option style="display: none;" value=""></option>
<option style="display: none;" value=""></option>
<option value="Intern/In-training">Intern/In-training</option>
<option value="Student - Undergraduate Study">Student - Undergraduate Study</option>
<option value="Student- Graduate Study">Student- Graduate Study</option>
<option value="Student - Post-graduate Study">Student - Post-graduate Study</option>
<option value="Student - Medical">Student - Medical</option>
<option value="Student- Medical Resident">Student- Medical Resident</option>
<option value="Other">Other</option>
</select></div>
<br><br> Area of Study? <input name="_AreaofStudy" type="text" style="width: 100%;">
<br>
</div>
<br> Highest Level of Education <br>
<div class="select_container"><select onchange="yesnoHeck(this);" name="_HighestLevelofEducation">
<option value="High School">High School</option>
<option value="Associates">Associates</option>
<option value="Bachelors">Bachelors</option>
<option value="Masters">Masters</option>
<option value="Doctorate">Doctorate</option>
</select></div>
<br>
<div id="ifA" style="display: none;">
<br> Associates <br>
<div class="select_container"><select name="_AssociatesDegree">
<option style="display: none;" value=""></option>
<option value="Associates AND">AND</option>
<option value="Associates ASN">ASN</option>
<option value="Associates AA/AAS/ADP">AA/AAS/ADP</option>
<option value="Associates Other">Other</option>
</select></div>
</div>
<div id="ifB" style="display: none;">
<br> Bachelors <br>
<div class="select_container"><select name="_BachelorsDegree">
<option style="display: none;" value=""></option>
<option value="Bachelors BA/BS">BA/BS</option>
<option value="Bachelors BS Ed">BS Ed</option>
<option value="Bachelors BSN">BSN</option>
<option value="Bachelors BSW">BSW</option>
<option value="Bachelors MBBS">MBBS</option>
<option value="Bachelors MBchB">MBchB</option>
<option value="Bachelors Other">Other</option>
</select></div>
</div>
<div id="ifM" style="display: none;">
<br> Masters <br>
<div class="select_container"><select name="_MastersDegree">
<option style="display: none;" value=""></option>
<option value="Masters MS">MS</option>
<option value="Masters MBA">MBA</option>
<option value="Masters MDiv">MDiv</option>
<option value="Masters MEd">MEd</option>
<option value="Masters MHA">MHA</option>
<option value="Masters MPA">MPA</option>
<option value="Masters MPAS">MPAS</option>
<option value="Masters MPH">MPH</option>
<option value="Masters MSMI">MSMI</option>
<option value="Masters MSN">MSN</option>
<option value="Masters MSW/MSSW">MSW/MSSW</option>
<option value="Masters MOT">MOT</option>
<option value="Masters MPT">MPT</option>
<option value="Masters Other">Other</option>
</select></div>
</div>
<div id="ifD" style="display: none;">
<br> Doctorate <br>
<div class="select_container"><select name="_DoctorateDegree">
<option style="display: none;" value=""></option>
<option value="Doctorate DPT">DPT</option>
<option value="Doctorate DO">DO</option>
<option value="Doctorate DNP">DNP</option>
<option value="Doctorate DNP-c">DNP-c</option>
<option value="Doctorate DHSc">DHSc</option>
<option value="Doctorate DrPH">DrPH</option>
<option value="Doctorate EdD">EdD</option>
<option value="Doctorate EDS">EDS</option>
<option value="Doctorate MD">MD</option>
<option value="Doctorate OTD">OTD</option>
<option value="Doctorate PhD">PhD</option>
<option value="Doctorate PsyD">PsyD</option>
<option value="Doctorate Other">Other</option>
</select></div>
</div>
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<legend class="gfield_label gform-field-label gfield_label_before_complex">Name<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
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<div id="field_58_8" class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible"
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<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_58_1">
<div class="gchoice gchoice_58_1_1">
<input class="gfield-choice-input" name="input_1.1" type="checkbox" value="I want to regularly learn through ECHO Autism Programs." id="choice_58_1_1">
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<legend class="gfield_label gform-field-label gfield_label_before_complex">Consent<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
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<div class="gfield_description gfield_consent_description" id="gfield_consent_description_58_3">By registering, you confirm your acknowledgement and consent to participate as a community partner for the Show-Me ECHO project. Community
partners agree to:<br>
<br> - Participate collegially in regularly scheduled Show-Me ECHO conferences by presenting cases, providing comments, asking questions;<br> - Keep confidential any patient information provided by other community partners during a
conference;<br> - Complete periodic surveys to help improve services to clinicians and other partners;<br> - Use required software including, but not limited to Zoom and Box;<br> - Provide clinical updates and de-identified outcome data on
patients as needed;<br> - Be solely responsible for the treatment of your patients and understand that all clinical decisions rest with you regardless of recommendations provided by other Show-Me ECHO participants and;<br> - Ensure that
your patients are aware of your participation in Show-Me ECHO and their de-identified information could be shared.<br> - Be photographed and recorded during Show-Me ECHO sessions.<br>
<br> In order to support the growth of the ECHO movement, Project ECHO® collects participation data for each teleECHO™ program. This data allows Project ECHO to measure, analyze, and report on the movement’s reach. Aggregate data is used in
reports, on maps and visualizations, for research, for communications and surveys, for data quality assurance activities, and for decision-making related to new initiatives.<br>
<br> By registering, you confirm your acknowledgement and consent to participate as a community partner for the Show-Me ECHO project.*
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<div id="field_58_9" class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_58_9">
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conference;<br> - Complete periodic surveys to help improve services to clinicians and other partners;<br> - Use required software including, but not limited to Zoom and Box;<br> - Provide clinical updates and de-identified outcome data on
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<br> In order to support the growth of the ECHO movement, Project ECHO® collects participation data for each teleECHO™ program. This data allows Project ECHO to measure, analyze, and report on the movement’s reach. Aggregate data is used in
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conference;<br> - Complete periodic surveys to help improve services to clinicians and other partners;<br> - Use required software including, but not limited to Zoom and Box;<br> - Be photographed and recorded during ECHO Autism Program
sessions.<br>
<br> In order to support the growth of the ECHO Autism Communities, ECHO Autism Programs collect participation data for each teleECHO™ program. This data allows measurement, analysis, and reporting on the movement’s reach. Aggregate data is
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conference;<br> - Complete periodic surveys to help improve services to clinicians and other partners;<br> - Use required software including, but not limited to Zoom and Box;<br> - Be photographed and recorded during ECHO Autism Program
sessions.<br>
<br> In order to support the growth of the ECHO Autism Communities, ECHO Autism Programs collect participation data for each teleECHO™ program. This data allows measurement, analysis, and reporting on the movement’s reach. Aggregate data is
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<div id="field_49_5" class="gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_49_5"><label
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<input class="gfield-choice-input" name="input_1.1" type="checkbox" value="I want to regularly learn through ECHO Autism Programs." id="choice_49_1_1" aria-describedby="gfield_description_49_1">
<label for="choice_49_1_1" id="label_49_1_1" class="gform-field-label gform-field-label--type-inline">I want to regularly learn through ECHO Autism Programs.</label>
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<input class="gfield-choice-input" name="input_1.2" type="checkbox" value="This is part of my training to run my own ECHO sessions." id="choice_49_1_2">
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<div class="gfield_description" id="gfield_description_49_1"><strong>Both of these options will let you receive all program invitations from this point forward. To stop receiving meeting information simply unsubscribe from any of the
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<fieldset id="field_49_3"
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<legend class="gfield_label gform-field-label gfield_label_before_complex">Consent<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_consent"><input name="input_3.1" id="input_49_3_1" type="checkbox" value="1" aria-describedby="gfield_consent_description_49_3" aria-required="true" aria-invalid="false"> <label
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<div class="gfield_description gfield_consent_description" id="gfield_consent_description_49_3">By registering, you confirm your acknowledgement and consent to participate as a community partner for the ECHO Autism Programs. Community
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conference;<br> - Complete periodic surveys to help improve services to clinicians and other partners;<br> - Use required software including, but not limited to Zoom and Box;<br> - Be photographed and recorded during ECHO Autism Program
sessions.<br>
<br> In order to support the growth of the ECHO Autism Communities, ECHO Autism Programs collect participation data for each teleECHO™ program. This data allows measurement, analysis, and reporting on the movement’s reach. Aggregate data is
used in reports, on maps and visualizations, for research, for communications and surveys, for data quality assurance activities, and for decision-making related to new initiatives.
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<ul id="gform_fields_1" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_1_4" class="gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_4">
<h2 class="gsection_title">Choose a program to attend</h2>
</li>
<li id="field_1_20" class="gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_20"><label class="gfield_label gform-field-label" for="input_1_20">Echo
Autism Programs</label>
<div class="ginput_container ginput_container_select">
<div class="select_container"><select name="input_20" id="input_1_20" class="medium gfield_select" aria-invalid="false">
<option value="Primary Care">Primary Care</option>
<option value="Psychology">Psychology</option>
<option value="School Psychology">School Psychology</option>
<option value="School Support">School Support</option>
<option value="Transition to adulthood">Transition to adulthood</option>
<option value="Crisis Care">Crisis Care</option>
<option value="Development & Support">Development & Support</option>
<option value="Behavior Analysis">Behavior Analysis</option>
</select></div>
</div>
</li>
<li id="field_1_19" class="gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_19">
<h2 class="gsection_title">Your Information</h2>
</li>
<li id="field_1_5" class="gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_5"><label class="gfield_label gform-field-label"
for="input_1_5">Name of Organization<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_5" id="input_1_5" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</li>
<li id="field_1_6" class="gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_6"><label class="gfield_label gform-field-label"
for="input_1_6">Phone<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_6" id="input_1_6" type="text" value="" class="medium" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_1_7" class="gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_7"><label
class="gfield_label gform-field-label gfield_label_before_complex">Organization's Address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row" id="input_1_7">
<span class="ginput_full address_line_1 ginput_address_line_1 gform-grid-col" id="input_1_7_1_container">
<input type="text" name="input_7.1" id="input_1_7_1" value="" aria-required="true">
<label for="input_1_7_1" id="input_1_7_1_label" class="gform-field-label gform-field-label--type-sub ">Street Address</label>
</span><span class="ginput_full address_line_2 ginput_address_line_2 gform-grid-col" id="input_1_7_2_container">
<input type="text" name="input_7.2" id="input_1_7_2" value="" aria-required="false">
<label for="input_1_7_2" id="input_1_7_2_label" class="gform-field-label gform-field-label--type-sub ">Address Line 2</label>
</span><span class="ginput_left address_city ginput_address_city gform-grid-col" id="input_1_7_3_container">
<input type="text" name="input_7.3" id="input_1_7_3" value="" aria-required="true">
<label for="input_1_7_3" id="input_1_7_3_label" class="gform-field-label gform-field-label--type-sub ">City</label>
</span><span class="ginput_right address_state ginput_address_state gform-grid-col" id="input_1_7_4_container">
<input type="text" name="input_7.4" id="input_1_7_4" value="" aria-required="true">
<label for="input_1_7_4" id="input_1_7_4_label" class="gform-field-label gform-field-label--type-sub ">State / Province / Region</label>
</span><span class="ginput_left address_zip ginput_address_zip gform-grid-col" id="input_1_7_5_container">
<input type="text" name="input_7.5" id="input_1_7_5" value="" aria-required="true">
<label for="input_1_7_5" id="input_1_7_5_label" class="gform-field-label gform-field-label--type-sub ">ZIP / Postal Code</label>
</span><span class="ginput_right address_country ginput_address_country gform-grid-col" id="input_1_7_6_container">
<div class="select_container"><select name="input_7.6" id="input_1_7_6" aria-required="true">
<option value="" selected="selected"></option>
<option value="Afghanistan">Afghanistan</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antarctica">Antarctica</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivia">Bolivia</option>
<option value="Bonaire, Sint Eustatius and Saba">Bonaire, Sint Eustatius and Saba</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Bouvet Island">Bouvet Island</option>
<option value="Brazil">Brazil</option>
<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
<option value="Brunei Darussalam">Brunei Darussalam</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cabo Verde">Cabo Verde</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Cocos Islands">Cocos Islands</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo">Congo</option>
<option value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option>
<option value="Cook Islands">Cook Islands</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Curaçao">Curaçao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czechia">Czechia</option>
<option value="Côte d'Ivoire">Côte d'Ivoire</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Eswatini">Eswatini</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Falkland Islands">Falkland Islands</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="France">France</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern Territories">French Southern Territories</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guernsey">Guernsey</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option>
<option value="Holy See">Holy See</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iran">Iran</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Isle of Man">Isle of Man</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jersey">Jersey</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Korea, Democratic People's Republic of">Korea, Democratic People's Republic of</option>
<option value="Korea, Republic of">Korea, Republic of</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macao">Macao</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Micronesia">Micronesia</option>
<option value="Moldova">Moldova</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montenegro">Montenegro</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="North Macedonia">North Macedonia</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestine, State of">Palestine, State of</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Pitcairn">Pitcairn</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Romania">Romania</option>
<option value="Russian Federation">Russian Federation</option>
<option value="Rwanda">Rwanda</option>
<option value="Réunion">Réunion</option>
<option value="Saint Barthélemy">Saint Barthélemy</option>
<option value="Saint Helena, Ascension and Tristan da Cunha">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Martin">Saint Martin</option>
<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia">Serbia</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Sint Maarten">Sint Maarten</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="South Georgia and the South Sandwich Islands">South Georgia and the South Sandwich Islands</option>
<option value="South Sudan">South Sudan</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syria Arab Republic">Syria Arab Republic</option>
<option value="Taiwan">Taiwan</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Tanzania, the United Republic of">Tanzania, the United Republic of</option>
<option value="Thailand">Thailand</option>
<option value="Timor-Leste">Timor-Leste</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Türkiye">Türkiye</option>
<option value="US Minor Outlying Islands">US Minor Outlying Islands</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="United States">United States</option>
<option value="Uruguay">Uruguay</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Venezuela">Venezuela</option>
<option value="Viet Nam">Viet Nam</option>
<option value="Virgin Islands, British">Virgin Islands, British</option>
<option value="Virgin Islands, U.S.">Virgin Islands, U.S.</option>
<option value="Wallis and Futuna">Wallis and Futuna</option>
<option value="Western Sahara">Western Sahara</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
<option value="Åland Islands">Åland Islands</option>
</select></div>
<label for="input_1_7_6" id="input_1_7_6_label" class="gform-field-label gform-field-label--type-sub ">Country</label>
</span>
<div class="gf_clear gf_clear_complex"></div>
</div>
</li>
<li id="field_1_8" class="gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_8"><label
class="gfield_label gform-field-label gfield_label_before_complex">Participant's Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row" id="input_1_8">
<span id="input_1_8_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
<input type="text" name="input_8.3" id="input_1_8_3" value="" aria-required="true">
<label for="input_1_8_3" class="gform-field-label gform-field-label--type-sub ">First</label>
</span>
<span id="input_1_8_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
<input type="text" name="input_8.6" id="input_1_8_6" value="" aria-required="true">
<label for="input_1_8_6" class="gform-field-label gform-field-label--type-sub ">Last</label>
</span>
</div>
</li>
<li id="field_1_9" class="gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_9"><label class="gfield_label gform-field-label"
for="input_1_9">Phone<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_9" id="input_1_9" type="text" value="" class="medium" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_1_10" class="gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_10"><label
class="gfield_label gform-field-label" for="input_1_10">Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_10" id="input_1_10" type="text" value="" class="medium" aria-required="true" aria-invalid="false">
</div>
</li>
<li id="field_1_12" class="gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_12"><label
class="gfield_label gform-field-label" for="input_1_12">Job Title<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_12" id="input_1_12" type="text" value="" class="medium" aria-required="true" aria-invalid="false"> </div>
</li>
<li id="field_1_13" class="gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_13"><label
class="gfield_label gform-field-label" for="input_1_13">Credentials<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_13" id="input_1_13" type="text" value="" class="medium" aria-required="true" aria-invalid="false"> </div>
</li>
<li id="field_1_14" class="gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_14"><label
class="gfield_label gform-field-label gfield_label_before_complex">Mailing Address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row" id="input_1_14">
<span class="ginput_full address_line_1 ginput_address_line_1 gform-grid-col" id="input_1_14_1_container">
<input type="text" name="input_14.1" id="input_1_14_1" value="" aria-required="true">
<label for="input_1_14_1" id="input_1_14_1_label" class="gform-field-label gform-field-label--type-sub ">Street Address</label>
</span><span class="ginput_full address_line_2 ginput_address_line_2 gform-grid-col" id="input_1_14_2_container">
<input type="text" name="input_14.2" id="input_1_14_2" value="" aria-required="false">
<label for="input_1_14_2" id="input_1_14_2_label" class="gform-field-label gform-field-label--type-sub ">Address Line 2</label>
</span><span class="ginput_left address_city ginput_address_city gform-grid-col" id="input_1_14_3_container">
<input type="text" name="input_14.3" id="input_1_14_3" value="" aria-required="true">
<label for="input_1_14_3" id="input_1_14_3_label" class="gform-field-label gform-field-label--type-sub ">City</label>
</span><span class="ginput_right address_state ginput_address_state gform-grid-col" id="input_1_14_4_container">
<input type="text" name="input_14.4" id="input_1_14_4" value="" aria-required="true">
<label for="input_1_14_4" id="input_1_14_4_label" class="gform-field-label gform-field-label--type-sub ">State / Province / Region</label>
</span><span class="ginput_left address_zip ginput_address_zip gform-grid-col" id="input_1_14_5_container">
<input type="text" name="input_14.5" id="input_1_14_5" value="" aria-required="true">
<label for="input_1_14_5" id="input_1_14_5_label" class="gform-field-label gform-field-label--type-sub ">ZIP / Postal Code</label>
</span><span class="ginput_right address_country ginput_address_country gform-grid-col" id="input_1_14_6_container">
<div class="select_container"><select name="input_14.6" id="input_1_14_6" aria-required="true">
<option value="" selected="selected"></option>
<option value="Afghanistan">Afghanistan</option>
<option value="Albania">Albania</option>
<option value="Algeria">Algeria</option>
<option value="American Samoa">American Samoa</option>
<option value="Andorra">Andorra</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antarctica">Antarctica</option>
<option value="Antigua and Barbuda">Antigua and Barbuda</option>
<option value="Argentina">Argentina</option>
<option value="Armenia">Armenia</option>
<option value="Aruba">Aruba</option>
<option value="Australia">Australia</option>
<option value="Austria">Austria</option>
<option value="Azerbaijan">Azerbaijan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahrain">Bahrain</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbados">Barbados</option>
<option value="Belarus">Belarus</option>
<option value="Belgium">Belgium</option>
<option value="Belize">Belize</option>
<option value="Benin">Benin</option>
<option value="Bermuda">Bermuda</option>
<option value="Bhutan">Bhutan</option>
<option value="Bolivia">Bolivia</option>
<option value="Bonaire, Sint Eustatius and Saba">Bonaire, Sint Eustatius and Saba</option>
<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
<option value="Botswana">Botswana</option>
<option value="Bouvet Island">Bouvet Island</option>
<option value="Brazil">Brazil</option>
<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
<option value="Brunei Darussalam">Brunei Darussalam</option>
<option value="Bulgaria">Bulgaria</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cabo Verde">Cabo Verde</option>
<option value="Cambodia">Cambodia</option>
<option value="Cameroon">Cameroon</option>
<option value="Canada">Canada</option>
<option value="Cayman Islands">Cayman Islands</option>
<option value="Central African Republic">Central African Republic</option>
<option value="Chad">Chad</option>
<option value="Chile">Chile</option>
<option value="China">China</option>
<option value="Christmas Island">Christmas Island</option>
<option value="Cocos Islands">Cocos Islands</option>
<option value="Colombia">Colombia</option>
<option value="Comoros">Comoros</option>
<option value="Congo">Congo</option>
<option value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option>
<option value="Cook Islands">Cook Islands</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Croatia">Croatia</option>
<option value="Cuba">Cuba</option>
<option value="Curaçao">Curaçao</option>
<option value="Cyprus">Cyprus</option>
<option value="Czechia">Czechia</option>
<option value="Côte d'Ivoire">Côte d'Ivoire</option>
<option value="Denmark">Denmark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominica">Dominica</option>
<option value="Dominican Republic">Dominican Republic</option>
<option value="Ecuador">Ecuador</option>
<option value="Egypt">Egypt</option>
<option value="El Salvador">El Salvador</option>
<option value="Equatorial Guinea">Equatorial Guinea</option>
<option value="Eritrea">Eritrea</option>
<option value="Estonia">Estonia</option>
<option value="Eswatini">Eswatini</option>
<option value="Ethiopia">Ethiopia</option>
<option value="Falkland Islands">Falkland Islands</option>
<option value="Faroe Islands">Faroe Islands</option>
<option value="Fiji">Fiji</option>
<option value="Finland">Finland</option>
<option value="France">France</option>
<option value="French Guiana">French Guiana</option>
<option value="French Polynesia">French Polynesia</option>
<option value="French Southern Territories">French Southern Territories</option>
<option value="Gabon">Gabon</option>
<option value="Gambia">Gambia</option>
<option value="Georgia">Georgia</option>
<option value="Germany">Germany</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Greece">Greece</option>
<option value="Greenland">Greenland</option>
<option value="Grenada">Grenada</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guernsey">Guernsey</option>
<option value="Guinea">Guinea</option>
<option value="Guinea-Bissau">Guinea-Bissau</option>
<option value="Guyana">Guyana</option>
<option value="Haiti">Haiti</option>
<option value="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option>
<option value="Holy See">Holy See</option>
<option value="Honduras">Honduras</option>
<option value="Hong Kong">Hong Kong</option>
<option value="Hungary">Hungary</option>
<option value="Iceland">Iceland</option>
<option value="India">India</option>
<option value="Indonesia">Indonesia</option>
<option value="Iran">Iran</option>
<option value="Iraq">Iraq</option>
<option value="Ireland">Ireland</option>
<option value="Isle of Man">Isle of Man</option>
<option value="Israel">Israel</option>
<option value="Italy">Italy</option>
<option value="Jamaica">Jamaica</option>
<option value="Japan">Japan</option>
<option value="Jersey">Jersey</option>
<option value="Jordan">Jordan</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kiribati">Kiribati</option>
<option value="Korea, Democratic People's Republic of">Korea, Democratic People's Republic of</option>
<option value="Korea, Republic of">Korea, Republic of</option>
<option value="Kuwait">Kuwait</option>
<option value="Kyrgyzstan">Kyrgyzstan</option>
<option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option>
<option value="Latvia">Latvia</option>
<option value="Lebanon">Lebanon</option>
<option value="Lesotho">Lesotho</option>
<option value="Liberia">Liberia</option>
<option value="Libya">Libya</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lithuania">Lithuania</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macao">Macao</option>
<option value="Madagascar">Madagascar</option>
<option value="Malawi">Malawi</option>
<option value="Malaysia">Malaysia</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malta">Malta</option>
<option value="Marshall Islands">Marshall Islands</option>
<option value="Martinique">Martinique</option>
<option value="Mauritania">Mauritania</option>
<option value="Mauritius">Mauritius</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexico">Mexico</option>
<option value="Micronesia">Micronesia</option>
<option value="Moldova">Moldova</option>
<option value="Monaco">Monaco</option>
<option value="Mongolia">Mongolia</option>
<option value="Montenegro">Montenegro</option>
<option value="Montserrat">Montserrat</option>
<option value="Morocco">Morocco</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibia">Namibia</option>
<option value="Nauru">Nauru</option>
<option value="Nepal">Nepal</option>
<option value="Netherlands">Netherlands</option>
<option value="New Caledonia">New Caledonia</option>
<option value="New Zealand">New Zealand</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigeria">Nigeria</option>
<option value="Niue">Niue</option>
<option value="Norfolk Island">Norfolk Island</option>
<option value="North Macedonia">North Macedonia</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Norway">Norway</option>
<option value="Oman">Oman</option>
<option value="Pakistan">Pakistan</option>
<option value="Palau">Palau</option>
<option value="Palestine, State of">Palestine, State of</option>
<option value="Panama">Panama</option>
<option value="Papua New Guinea">Papua New Guinea</option>
<option value="Paraguay">Paraguay</option>
<option value="Peru">Peru</option>
<option value="Philippines">Philippines</option>
<option value="Pitcairn">Pitcairn</option>
<option value="Poland">Poland</option>
<option value="Portugal">Portugal</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Qatar">Qatar</option>
<option value="Romania">Romania</option>
<option value="Russian Federation">Russian Federation</option>
<option value="Rwanda">Rwanda</option>
<option value="Réunion">Réunion</option>
<option value="Saint Barthélemy">Saint Barthélemy</option>
<option value="Saint Helena, Ascension and Tristan da Cunha">Saint Helena, Ascension and Tristan da Cunha</option>
<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
<option value="Saint Lucia">Saint Lucia</option>
<option value="Saint Martin">Saint Martin</option>
<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
<option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="San Marino">San Marino</option>
<option value="Sao Tome and Principe">Sao Tome and Principe</option>
<option value="Saudi Arabia">Saudi Arabia</option>
<option value="Senegal">Senegal</option>
<option value="Serbia">Serbia</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapore">Singapore</option>
<option value="Sint Maarten">Sint Maarten</option>
<option value="Slovakia">Slovakia</option>
<option value="Slovenia">Slovenia</option>
<option value="Solomon Islands">Solomon Islands</option>
<option value="Somalia">Somalia</option>
<option value="South Africa">South Africa</option>
<option value="South Georgia and the South Sandwich Islands">South Georgia and the South Sandwich Islands</option>
<option value="South Sudan">South Sudan</option>
<option value="Spain">Spain</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Sudan">Sudan</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
<option value="Sweden">Sweden</option>
<option value="Switzerland">Switzerland</option>
<option value="Syria Arab Republic">Syria Arab Republic</option>
<option value="Taiwan">Taiwan</option>
<option value="Tajikistan">Tajikistan</option>
<option value="Tanzania, the United Republic of">Tanzania, the United Republic of</option>
<option value="Thailand">Thailand</option>
<option value="Timor-Leste">Timor-Leste</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Trinidad and Tobago">Trinidad and Tobago</option>
<option value="Tunisia">Tunisia</option>
<option value="Turkmenistan">Turkmenistan</option>
<option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Türkiye">Türkiye</option>
<option value="US Minor Outlying Islands">US Minor Outlying Islands</option>
<option value="Uganda">Uganda</option>
<option value="Ukraine">Ukraine</option>
<option value="United Arab Emirates">United Arab Emirates</option>
<option value="United Kingdom">United Kingdom</option>
<option value="United States">United States</option>
<option value="Uruguay">Uruguay</option>
<option value="Uzbekistan">Uzbekistan</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Venezuela">Venezuela</option>
<option value="Viet Nam">Viet Nam</option>
<option value="Virgin Islands, British">Virgin Islands, British</option>
<option value="Virgin Islands, U.S.">Virgin Islands, U.S.</option>
<option value="Wallis and Futuna">Wallis and Futuna</option>
<option value="Western Sahara">Western Sahara</option>
<option value="Yemen">Yemen</option>
<option value="Zambia">Zambia</option>
<option value="Zimbabwe">Zimbabwe</option>
<option value="Åland Islands">Åland Islands</option>
</select></div>
<label for="input_1_14_6" id="input_1_14_6_label" class="gform-field-label gform-field-label--type-sub ">Country</label>
</span>
<div class="gf_clear gf_clear_complex"></div>
</div>
</li>
<li id="field_1_16" class="gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_16"><label
class="gfield_label gform-field-label gfield_label_before_complex">Please select which device(s) you will be using to participate in ECHO Autism:<span class="gfield_required"><span
class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_1_16">
<li class="gchoice gchoice_1_16_1">
<input class="gfield-choice-input" name="input_16.1" type="checkbox" value="Tablet (iPad or Surface)" id="choice_1_16_1">
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AUTISM
Health Professionals
BRINGING THE BEST AUTISM
CARE TO LOCAL COMMUNITIES
Families
THIS IS WHO WE ARE
ECHO AUTISM: MOVING KNOWLEDGE, NOT PEOPLE
THROUGH TELEMENTORING, ECHO CREATES ACCESS TO HIGH-QUALITY SPECIALTY CARE IN
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FAMILIES
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KNOWLEDGE-SHARING NETWORKS CREATE A LEARNING LOOP
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WHO WE WORK WITH
COLLABORATION
MISSOURI TELEHEALTH NETWORK
In Missouri, telehealth is defined as the delivery of health care services by
means of information and communication technologies, which facilitate the
assessment, diagnosis, consultation, treatment, education, care management, and
self-management of a patient’s health care while such a patient is at the
originating site and the health care provider is at the distant site.
The Autism Care Network is the first and only network of its kind focused
on better autism care, delivered at scale and at speed, to improve health
and quality of life for children with autism and their families throughout North
America. Launched in April 2021, the Network is supported by Autism Speaks,
AIR-P, the J. Donald Lee and Laurelle Lee Family Foundation and PCORnet.
ECHO Autism Communities is about equipping all communities to care for and
support individuals with autism and their families through best practices,
regardless of geographic location. Utilizing the ECHO Autism Model to mentor and
guide community practitioners, educators, and advocates, creating local
expertise and increasing access for individuals with autism and their families.
TESTIMONIALS
THE BUZZ ABOUT ECHO AUTISM
“MAKING SURE TO LET FAMILIES KNOW THAT WE ARE ALL IN THIS TOGETHER.”
“I WILL WORK HARDER TO SUPPORT MY FAMILIES.”
“I THINK IT WAS GOOD TO LEARN THE PARENT’S PERSPECTIVE OF THE GRIEVING PROCESS.
EVERY DAY MAY BE DIFFERENT IN THE CYCLE.”
“I APPRECIATE THE INVALUABLE INPUT FROM ALICIA AS A PARENT WHO HAS A CHILD WITH
AUTISM. SHE HAS VERY GOOD INSIGHT AND HELPS US ALL THINK ABOUT THIS FROM BOTH
SIDES!”
“MAKING SURE TO LET FAMILIES KNOW THAT WE ARE ALL IN THIS TOGETHER.”
“I WILL WORK HARDER TO SUPPORT MY FAMILIES.”
HELPFUL AUTISM SUPPORT
RESOURCES
GUIDE TO MANAGING CONSTIPATION
PICA GUIDE
SAFETY & WANDERING PREVENTION CHECKLIST
VISION EXAM GUIDE
DENTAL VISIT TOOL KIT
INDIVIDUALIZED EDUCATION PROGRAM
A PARENTS GUIDE TO AUTISM
FIRST CONCERN TO ACTION
100 DAY KIT FOR NEWLY DIAGNOSED FAMILIES
APPLIED BEHAVIOR ANALYSIS
BEHAVIORAL HEALTH TREATMENT
AUTISM & MEDICINE FOR CHALLENGING BEHAVIOR
EXPLORING FEEDING BEHAVIOR IN AUTISM
GUIDE TO MANAGING CONSTIPATION
PICA GUIDE
SAFETY & WANDERING PREVENTION CHECKLIST
VISION EXAM GUIDE
DENTAL VISIT TOOL KIT
INDIVIDUALIZED EDUCATION PROGRAM
A PARENTS GUIDE TO AUTISM
FIRST CONCERN TO ACTION
100 DAY KIT FOR NEWLY DIAGNOSED FAMILIES
APPLIED BEHAVIOR ANALYSIS
BEHAVIORAL HEALTH TREATMENT
AUTISM & MEDICINE FOR CHALLENGING BEHAVIOR
EXPLORING FEEDING BEHAVIOR IN AUTISM
GUIDE TO MANAGING CONSTIPATION
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OUR BLOG
RECENT POSTS
Echo Autism, Education
February 6, 2023
ECHO AUTISM COMMUNITIES SYMPOSIUM RETURNS
Uncategorized
February 28, 2022
ECHO AUTISM COMMUNITIES SYMPOSIUM RETURNS
News
September 3, 2021
HALEY MOSS STOPS BY TO CHAT WITH ECHO AUTISM
Blog
HOW WE CAN HELP YOU?
HAVE ANY QUESTIONS?
Thank you for reaching out to ECHO Autism Communities (EAC); we are so glad that
you found us. EAC is not a direct service provider and is limited to providing
resources for autistic people, families, and community stakeholders. We provide
training for professionals on best practices as it relates to autism. We also
provide digital resources to families, community members, and clinicians about
autism best practices. We are not able to answer medical questions or provide
individualized resource suggestions.
Thank you for your interest in ECHO Autism Communities.
We appreciate your support in achieving our goal of seeing possibilities in all
abilities.
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ADVANCED DIAGNOSIS ECHO PROGRAMS
LOCATION:
400 North Keene Street, Columbia, MO, USA
PROGRAM INFORMATION:
Target Audience: Clinical Psychologists; Physician Diagnosticians
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ABA ECHO PROGRAMS
CENTER FOR AUTISM & NEURODEVELOPMENTAL DISORDERS, UNIVERSITY OF CALIFORNIA
IRVINE
LOCATION:
2500 Red Hill Avenue #100, Santa Ana, CA 92705
PROGRAM INFORMATION:
ECHO Autism: ABA
CONTACT INFORMATION:
Email: thecenter4autism@uci.edu
Website: https://www.thecenter4autism.org/educationandtraining/
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promote its programs statewide/internationally. I hereby give my permission for
said information to be used in both internal and external publications, social
media, and videos.
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SYMPOSIUM 2023 REGISTRATION
Once you submit this registration you will need to complete the following Zoom
registration in order to access the Symposium.
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First Last
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I Consent to ECHO Autism Communities Release Agreement
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promote its programs statewide/internationally. I hereby give my permission for
said information to be used in both internal and external publications, social
media, and videos.
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promote its programs statewide/internationally. I hereby give my permission for
said information to be used in both internal and external publications, social
media, and videos.
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promote its programs statewide/internationally. I hereby give my permission for
said information to be used in both internal and external publications, social
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AMBER PERKINS, PSYD
THE ARC OF THE OZARKS
1501 East Pythian, Springfield, MO 65807
417-864-7887
Website
CYNTHIA TAYLOR, PHD
TAYLOR PSYCHOLOGICAL SERVICES, LLC
10918 Elm Avenue, Kansas City 64134
816-765-6600
Website
DAVID DAHLBECK, PHD
FERGUSON MEDICAL GROUP
1012 N Main St, Sikeston, MO 63801, USA
573-471-0330
Website
ELIZABETH TEEL, PSYD
CENTRAL OZARKS MEDICAL CENTER
304 W Washington, Richland, MO 65556
573-765-5141
Website
EMILY CRAWFORD THOMPSON, PHD
COLUMBIA PSYCHOLOGY HEALING CENTER
1900 N. Providence Rd. Suite 327, Columbia MO 65202
573-818-7010
Website
IVONNE OCAMPO, PHD
BURRELL BEHAVIORAL HEALTH
1675 E Seminole St Suite A1, Springfield MO 65804
417-597-4309
Website
JAMIE SCACCIA, PSYD
FAMILY FORWARD
1167 Corporate Lake Drive, St. Louis MO 63132
314-968-2350
Website
JENNIFER BLACKSMITH, PHD
NORTHEAST MISSOURI HEALTH COUNCIL
1416 Crown Drive, Kirksville, MO 63501
660-627-5757
Website
JULIE O'DONNELL, PHD
LIVEWELL COMMUNITY HEALTH CENTER
811 S Business Highway 13, Lexington MO 64067
660-251-6440
Website
JUSTIN JONES, PSYD
BURRELL BEHAVIORAL HEALTH
4480 Gretna Road, Branson MO 65616
417-761-5000
Website
KELLY WRIGHT, MD
COX HEALTH /NORTHSIDE PEDIATRICS & ADOLESCENTS
1443 N. Robberson #200, Springfield, MO 65802
417-269-8061
Website
LINDSAY ORAM, PHD
NORTH CENTRAL MISSOURI PSYCHOLOGICAL SERVICES
1301 Main Street, Trenton, MO 64683
660-359-4487
Website
LORETTA FUGE, PSYD
GREATER OZARKS RURAL PSYCHOLOGIST
827 W Commercial St Mansfield, MO 65704
417-924-8188
Website
MARY BRANT, PHD
PREFERRED FAMILY HEALTHCARE
1628 Oklahoma Ave, Trenton MO 64683
660-359-4600
Website
NADIN RIZK PSYD
HEALING GRACE COUNSELING CENTER
1272 NE Windsor Dr, Lee’s Summit 64086
816-246-4465 ext. 6
Website
RACHEL LINNEMEYER PHD
TRUMAN MEDICAL CENTER - LAKEWOOD COUNSELING SERVICE
300 SE Second Street, Lee’s Summit 64063
816-404-6170
Website
RACHAEL SWOPES, PHD
BUTTERFIELD PEDIATRICS
1195 N. Oakland, Bolivar, MO 65613
417-777-2121
Website
RHIANNON MOORE, PSYD
SAINT LUKE'S PHYSICIAN GROUP
10918 Elm Avenue, Kansas City MO 64134
816-767-4346
Website
SANDRA CLARK, PHD
QUINCEY MEDICAL GROUP
1025 Maine Street, Quincey, IL 62301
217-222-6550
Website
STACY BARHAM, PSYD
GREATER OZARKS RURAL PSYCHOLOGIST
827 W Commercial St Mansfield, MO 65704
417-924-8188
Website
SUSAN SHUMAN, PSYD
FAMILY LIFE COUNSELING
4142 Keaton Crossing Blvd, O’Fallon, MO 63368, USA
636-300-9333
Website
TRENT MYERS MD
TRUMAN MEDICAL CENTER - LAKEWOOD COUNSELING SERVICE
300 SE Second Street, Lee’s Summit 64063
816-404-6170
Website
WILLIAM WRIGHT, MD
TEXAS COUNTY MEMORIAL HOSPITAL
1337 S Sam Houston Blvd, Houston, MO 65483
417-967-5639
Website
×
ASHLEE JONES, PSYD
TRUMAN MEDICAL CENTER
300 W 19th Terrace, Kansas City, MO 64108
816-404-6039
Website
ASHLEY CROSS, PLPC
EMBARK COUNSELING SERVICES
8350 N St. Clair, Suite 275, Kansas City, MO 64151
913-257-3161
Website
BRIN BALLARD, MA, LPC
BRIN BALLARD MENTAL HEALTH SERVICES
1303 Edgewood Dr., Jefferson City, MO 65109
660-221-0659
Website
CLAUDINE ALLEN, LPC
ALM HOPEWELL
5647 Delmar, St Louis., MO 63112
314-531-1770
Website
COSHA PETERSON, PHD
COMPASS HEALTH
Bldg 6 #220b, 1000 W Nifong Blvd, Columbia, MO 65203
573-442-1690
Website
COURTNEY MILLER, LPC, NCC
MARK TWAIN BEHAVIORAL HEALTH
154 Forrest Drive, Hannibal, MO 63401
573-221-2120
Website
DAWN ORTEGA, LCP
COMTREA
110 N Mill Street, Festus, MO 63028
636-931-2700
Website
DEANNA WOLF, PSY.D.
BURRELL BEHAVIORAL HEALTH
1300 E Bradford Parkway, Springfield, MO 65804
417-761-5453
Website
DIANE SILMAN, LCSW
MISSOURI HIGHLANDS
1018 S. Westwood Blvd. Suite 4, Poplar Bluff, MO 63901
573-351-1242
Website
ERIN CLOUD, LMSW
BURRELL BEHAVIORAL HEALTH
1300 E Bradford Parkway, Springfield, MO 65804
417-761-5453
Website
JAMIE CROUCH, LPC
MARK TWAIN BEHAVIORAL HEALTH
105 Pfieffer, Kirksville, MO 63501
660-665-4612
Website
LORA SHREVE, LPC
BURRELL BEHAVIORAL HEALTH
102 West Buchanan Street, California, MO 65018
573-777-7501
Website
NATALIE CARVER, PSYD, LPC
BURRELL BEHAVIORAL HEALTH
1300 E Bradford Parkway, Springfield, MO 65804
417-761-5453
Website
PATRICIA HINTEN, PLPC
COLUMBIA PSYCHOLOGY HEALING CENTER
1900 Vandiver, Columbia, MO 65202
573-818-7010
Website
PHILLIP SMITH, LPC
COMPASS HEALTH
1450 E 10th Street, Rolla, MO 65401
844-853-8937
Website
ROBIN RASSE, LPC
BURRELL BEHAVIORAL HEALTH
33 E Jackson Street, Marshall, MO 65340
660-886-8063
Website
ROCHELLE MORGAN, LPC
COMPASS HEALTH
101 Progress Drive, Sullivan, MO 63080
844-853-8937
Website
SANDRA CLARK, PH.D., LCSP
QUINCY MEDICAL GROUP
1101 Maine Street, Quincy, IL 62301
217-222-6550
Website
SARAH LEA, PH.D., LPC
COMPASS HEALTH
1450 E 10th Street, Rolla, MO 65401
573-201-6292
Website
TABATHA RICE, LPC
BURRELL BEHAVIORAL HEALTH
210 N Williams St., Moberly, MO 65270
660-263-7651
Website
TINA KIRCHNER, LPC
COMPASS HEALTH
1905 Stadium Blvd, Jefferson City, MO 65109
573-301-9091
Website
VALERY JOHNSON, LPC
COMPASS HEALTH
616 Burkarth, Warrensburg, MO 64093
660-207-7311
Website
×
AFTEN ANDERSON, MD
GOLDEN VALLEY MEMORIAL HEALTHCARE
1602 N 2nd St, Clinton MO 64735
660-890-8000
Website
ALEXANDRA JAMES, MD
MU PEDIATRICS
511 E Southhampton Dr, Columbia, MO 65201
573-882-4730
Website
AMANDA WILLIAMS, MD
PEACOCK PEDIATRICS
902 N Riverside Rd St, Joseph, MO 64507
816-271-4990
Website
BETH CRAWFORD, MD
SSM MEDICAL GROUP PEDIATRICS
3348 American Ave, Jefferson City, MO 65109
573-761-7979
Website
BETH WOOLERY GARRETT, MD
FREEMAN HEALTH SYSTEM
1030 Mcintosh Cir, Joplin, MO 64804
417-347-8750
Website
BRETT MOORE, MD
MU PEDIATRICS
511 E Southhampton Dr, Columbia, MO 65201
573-882-4730
Website
CLAUDIA PREUSCHOFF, MD
POPLAR BLUFF PEDIATRICS
2210 Barron Rd, Poplar Bluff, MO 63901, USA
573-785-2005
Website
DANA KAPP, APRN
PEACOCK PEDIATRICS
805 B, N 36th Street, St Joseph, MO 64506
816-396-6026
Website
JASMINE EL KHATIB, DO
CHCCMO
1511 Christy Drive, Jefferson City, MO 65109
573-632-2777
Website
JAMIE BALL, MD
GOLDEN VALLEY MEMORIAL HEALTHCARE
1602 N 2nd Street, Clinton, MO 64735
660-885-8171
Website
JOANN MARTIN, CPNP
PETTIS COUNTY HEALTH CENTER
911 E 16th Street, Sedalia, MO 65301
660-827-1130
Website
JOHN WILSON, MD
COMO CUBS
201 W Broadway Suite 4A Columbia, MO 65203
573-443-0937
Website
KARIN CLAUSS MORTON, MD
BJC-MEDICAL ARTS CLINIC
1103 W. Liberty St. t Suite 2018, Farmington, MO 63640
855-646-7267
Website
KELLY WRIGHT, MD
NORTHSIDE PEDIATRICS AND ADOLESCENTS
1443 N Robberson, Springfield, MO 65802
417-269-8061
Website
KRISTEN THEOBALD HAZEL, DO
LAKE REGIONAL HOSPITALS AND CLINICS- OSAGE BEACH CLINIC
1057 Medical Park Drive, Building 2, Osage Beach, MO 65065
573-302-7490
Website
LAURA WATERS, MD
MERCY
4331 S Fremont Ave, Springfield, MO 65804, USA
417-820-5000
Website
MICHELLE CEBULKO, MD
PEACOCK PEDIATRICS
805 B, N 36th Street, St Joseph, MO 64506
816-396-6026
Website
MICHELLE KENNEY, MD
NORTHEAST PEDIATRICS
402 W Jefferson St, Kirksville, MO 63501
660-627-2229
Website
NARAYAN VELIGATI, MD
MOSAIC INTERNAL MEDICINE AND PEDIATRICS
5514 Corporate Dr. Suite 120, St Joseph, MO 64506
816-271-6000
Website
RHIANNON SANDERS, MD
MERCY
608 Old Rte 66, St. Robert, MO 65584
573-336-8990
Website
WILLIAM “BILL” WRIGHT, MD
TEXAS COUNTY MEMORIAL HOSPITAL
1337 S Sam Houston Blvd Houston, MO 65483
417-967-5639
Website
RONDA AZELTON, DO
COX FAMILY PRACTICE AND OB
815 N Lincoln Ave, Monett, MO 65708
417-354-1500
Website
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ELAINA MENSINGER, BCBA
UNITED SERVICES FOR CHILDREN / UNCOMMON GRACE
4140 Old Mill Parkway, St. Peters, MO 63376
636-926-2700
Website
PEGGY HAMMOND, BCBA
UNITED SERVICES FOR CHILDREN / UNCOMMON GRACE
4140 Old Mill Parkway, St. Peters, MO 63376
636-926-2700
Website
LAURA BAILEY, MS, BCBA, LBA
RIVENDALE INSTITUTE OF LEARNING AND AUTISM
1721 West Elfindale Drive, Springfield, MO 65807
417-864-7921
Website
LAURA BARNES, MS, BCBA, LBA
UCP HEARTLAND
25 S Fourth Street, Columbia, MO 65201
573-222-0010
Website
VERONICA SCHAMA, BCBA, LBA
BETHESDA LUTHERAN COMMUNITIES
2536 South Old Highway 94, Suite 214, St Charles, MO 63303
573-987-7150
Website
AMANDA RIVIELLO, BCBA
CHILDREN'S BEHAVIORAL SERVICES, LLC
910 Springfield Road, Willow Springs, MO 65793
573-883-6761
Website
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Paramedic Exercise Science Professional (trainer, physiologist) Genetic
Counselor/Genetic Assistants Kinesiotherapist Lactation Consultant Magnetic
Resonance Technologist (MRI) Medical Assistant Music Therapist Phlebotomist
Radiologist Respiratory Therapist Other
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ACCNS ANP APN APRN APRN-BC BC FNP C-FNP CNL CNS CPNP/CPNP-PC CS FNP/FNP-BC/FNP-C
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Child and Adolescent Other
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Family Medicine Internal Medicine - General Internal Medicine-Pediatrics
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Child and Adolescent Other
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Psychology - Clinical Psychology - Counseling Psychology - Neuro Psychology -
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Case Manager/Coordinator Clinician/Therapist/Counselor Supervisor Other
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High School Associates Bachelors Masters Doctorate
Associates
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MS MBA MDiv MEd MHA MPA MPAS MPH MSMI MSN MSW/MSSW MOT MPT Other
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I want to regularly learn through ECHO Autism Programs.
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Both of these options will let you receive all program invitations from this
point forward. To stop receiving meeting information simply unsubscribe from any
of the emails.
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I agree to the ECHO Autism Programs conditions of participation
By registering, you confirm your acknowledgement and consent to participate as a
community partner for the ECHO Autism Programs. Community partners agree to:
- Participate collegially in regularly scheduled ECHO Autism Programs
conferences by presenting cases, providing comments, asking questions;
- Keep confidential any patient information provided by other community partners
during a conference;
- Complete periodic surveys to help improve services to clinicians and other
partners;
- Use required software including, but not limited to Zoom and Box;
- Be photographed and recorded during ECHO Autism Program sessions.
In order to support the growth of the ECHO Autism Communities, ECHO Autism
Programs collect participation data for each teleECHO™ program. This data allows
measurement, analysis, and reporting on the movement’s reach. Aggregate data is
used in reports, on maps and visualizations, for research, for communications
and surveys, for data quality assurance activities, and for decision-making
related to new initiatives.
Consent(Required)
I agree to the privacy policy.
By checking this box, you agree to allow us to store the data from this form and
agree to receive further email communication about our products/services and
other news. You can change your mind at any time by contacting us or clicking
the unsubscribe link on any email.
Δ
×
CENTER ENGAGEMENT PROGRAM INTEREST
Name(Required)
First Last
Email(Required)
Message for Program Coordinator(Required)
Δ
×
ECHO 4 ECHO PROGRAM INTEREST
Name(Required)
First Last
Email(Required)
Message for Program Coordinator(Required)
Δ
×
MENTAL HEALTH PROGRAM INTEREST
Name(Required)
First Last
Email(Required)
Message for Program Coordinator(Required)
Δ
×
PRIMARY CARE ECHO REGISTRATION
Email / Username Used to Login(Required)
Participation Status:(Required)
I want to regularly learn through ECHO Autism Programs.
This is part of my training to run my own ECHO sessions.
I help run ECHO sessions (staff).
Consent(Required)
I agree to the ECHO Autism Programs conditions of participation
By registering, you confirm your acknowledgement and consent to participate as a
community partner for the Show-Me ECHO project. Community partners agree to:
- Participate collegially in regularly scheduled Show-Me ECHO conferences by
presenting cases, providing comments, asking questions;
- Keep confidential any patient information provided by other community partners
during a conference;
- Complete periodic surveys to help improve services to clinicians and other
partners;
- Use required software including, but not limited to Zoom and Box;
- Provide clinical updates and de-identified outcome data on patients as needed;
- Be solely responsible for the treatment of your patients and understand that
all clinical decisions rest with you regardless of recommendations provided by
other Show-Me ECHO participants and;
- Ensure that your patients are aware of your participation in Show-Me ECHO and
their de-identified information could be shared.
- Be photographed and recorded during Show-Me ECHO sessions.
In order to support the growth of the ECHO movement, Project ECHO® collects
participation data for each teleECHO™ program. This data allows Project ECHO to
measure, analyze, and report on the movement’s reach. Aggregate data is used in
reports, on maps and visualizations, for research, for communications and
surveys, for data quality assurance activities, and for decision-making related
to new initiatives.
By registering, you confirm your acknowledgement and consent to participate as a
community partner for the Show-Me ECHO project.*
Consent(Required)
I agree to the privacy policy.
By checking this box, you agree to allow us to store the data from this form and
agree to receive further email communication about our products/services and
other news. You can change your mind at any time by contacting us or clicking
the unsubscribe link on any email.
Δ
×
BEHAVIORAL INTERVENTION ECHO REGISTRATION
Email / Username Used to Login(Required)
Participation Status:(Required)
I want to regularly learn through ECHO Autism Programs.
This is part of my training to run my own ECHO sessions.
I help run ECHO sessions (staff).
Consent(Required)
I agree to the ECHO Autism Programs conditions of participation
By registering, you confirm your acknowledgement and consent to participate as a
community partner for the Show-Me ECHO project. Community partners agree to:
- Participate collegially in regularly scheduled Show-Me ECHO conferences by
presenting cases, providing comments, asking questions;
- Keep confidential any patient information provided by other community partners
during a conference;
- Complete periodic surveys to help improve services to clinicians and other
partners;
- Use required software including, but not limited to Zoom and Box;
- Provide clinical updates and de-identified outcome data on patients as needed;
- Be solely responsible for the treatment of your patients and understand that
all clinical decisions rest with you regardless of recommendations provided by
other Show-Me ECHO participants and;
- Ensure that your patients are aware of your participation in Show-Me ECHO and
their de-identified information could be shared.
- Be photographed and recorded during Show-Me ECHO sessions.
In order to support the growth of the ECHO movement, Project ECHO® collects
participation data for each teleECHO™ program. This data allows Project ECHO to
measure, analyze, and report on the movement’s reach. Aggregate data is used in
reports, on maps and visualizations, for research, for communications and
surveys, for data quality assurance activities, and for decision-making related
to new initiatives.
By registering, you confirm your acknowledgement and consent to participate as a
community partner for the Show-Me ECHO project.*
Consent(Required)
I agree to the privacy policy.
By checking this box, you agree to allow us to store the data from this form and
agree to receive further email communication about our products/services and
other news. You can change your mind at any time by contacting us or clicking
the unsubscribe link on any email.
Δ
×
FAMILY ADVOCATES ECHO REGISTRATION
Email / Username Used to Login(Required)
Participation Status:(Required)
I want to regularly learn through ECHO Autism Programs.
This is part of my training to run my own ECHO sessions.
Both of these options will let you receive all program invitations from this
point forward. To stop receiving meeting information simply unsubscribe from any
of the emails.
Consent(Required)
I agree to the ECHO Autism Programs conditions of participation
By registering, you confirm your acknowledgement and consent to participate as a
community partner for the ECHO Autism Programs. Community partners agree to:
- Participate collegially in regularly scheduled ECHO Autism Programs
conferences by presenting cases, providing comments, asking questions;
- Keep confidential any patient information provided by other community partners
during a conference;
- Complete periodic surveys to help improve services to clinicians and other
partners;
- Use required software including, but not limited to Zoom and Box;
- Be photographed and recorded during ECHO Autism Program sessions.
In order to support the growth of the ECHO Autism Communities, ECHO Autism
Programs collect participation data for each teleECHO™ program. This data allows
measurement, analysis, and reporting on the movement’s reach. Aggregate data is
used in reports, on maps and visualizations, for research, for communications
and surveys, for data quality assurance activities, and for decision-making
related to new initiatives.
Consent(Required)
I agree to the privacy policy.
By checking this box, you agree to allow us to store the data from this form and
agree to receive further email communication about our products/services and
other news. You can change your mind at any time by contacting us or clicking
the unsubscribe link on any email.
Δ
×
EARLY INTERVENTION ECHO REGISTRATION
Email / Username Used to Login(Required)
Participation Status:(Required)
I want to regularly learn through ECHO Autism Programs.
This is part of my training to run my own ECHO sessions.
Both of these options will let you receive all program invitations from this
point forward. To stop receiving meeting information simply unsubscribe from any
of the emails.
Consent(Required)
I agree to the ECHO Autism Programs conditions of participation
By registering, you confirm your acknowledgement and consent to participate as a
community partner for the ECHO Autism Programs. Community partners agree to:
- Participate collegially in regularly scheduled ECHO Autism Programs
conferences by presenting cases, providing comments, asking questions;
- Keep confidential any patient information provided by other community partners
during a conference;
- Complete periodic surveys to help improve services to clinicians and other
partners;
- Use required software including, but not limited to Zoom and Box;
- Be photographed and recorded during ECHO Autism Program sessions.
In order to support the growth of the ECHO Autism Communities, ECHO Autism
Programs collect participation data for each teleECHO™ program. This data allows
measurement, analysis, and reporting on the movement’s reach. Aggregate data is
used in reports, on maps and visualizations, for research, for communications
and surveys, for data quality assurance activities, and for decision-making
related to new initiatives.
Consent(Required)
I agree to the privacy policy.
By checking this box, you agree to allow us to store the data from this form and
agree to receive further email communication about our products/services and
other news. You can change your mind at any time by contacting us or clicking
the unsubscribe link on any email.
Δ
×
PSYCHOLOGY ECHO REGISTRATION
Email / Username Used to Login(Required)
Participation Status:(Required)
I want to regularly learn through ECHO Autism Programs.
This is part of my training to run my own ECHO sessions.
Both of these options will let you receive all program invitations from this
point forward. To stop receiving meeting information simply unsubscribe from any
of the emails.
Consent(Required)
I agree to the ECHO Autism Programs conditions of participation
By registering, you confirm your acknowledgement and consent to participate as a
community partner for the ECHO Autism Programs. Community partners agree to:
- Participate collegially in regularly scheduled ECHO Autism Programs
conferences by presenting cases, providing comments, asking questions;
- Keep confidential any patient information provided by other community partners
during a conference;
- Complete periodic surveys to help improve services to clinicians and other
partners;
- Use required software including, but not limited to Zoom and Box;
- Be photographed and recorded during ECHO Autism Program sessions.
In order to support the growth of the ECHO Autism Communities, ECHO Autism
Programs collect participation data for each teleECHO™ program. This data allows
measurement, analysis, and reporting on the movement’s reach. Aggregate data is
used in reports, on maps and visualizations, for research, for communications
and surveys, for data quality assurance activities, and for decision-making
related to new initiatives.
Consent(Required)
I agree to the privacy policy.
By checking this box, you agree to allow us to store the data from this form and
agree to receive further email communication about our products/services and
other news. You can change your mind at any time by contacting us or clicking
the unsubscribe link on any email.
Δ
×
Meeting Schedule:
1st and 3rd Thursdays
12:00 pm – 1:00 pm CST
Nov – April
Request More Info
×
Meeting Schedule:
1st & 3rd Thursdays
12:00 pm – 1:15pm MST
May – December
Request More Info
Meeting Schedule:
1st and 3rd Fridays
12:00 pm – 1:30 pm EST
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×
Meeting Schedule:
Tuesdays (1st and 3rd)
1:00pm – 2:00pm EST
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Meeting Schedule:
Wednesday (2nd)
12:00 – 1:00 EST
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×
Meeting Schedule:
Tuesdays (1st and 3rd) 1:00pm – 2:00pm EST
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×
Meeting Schedule:
Thursday (2nd and 4th)
12:30 – 2:00 PST
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Meeting Schedule:
Wednesday (1st and 3rd)
12:00 – 1:30 EST
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Meeting Schedule:
Wednesday (2nd and 4th)
12:00 – 1:00 PST
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Meeting Schedule:
Friday (1st and 3rd)
12:00 – 1:00 EST
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Meeting Schedule:
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Meeting Schedule:
Thursday (1st and 3rd)
12:00 – 1:00 EST
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Meeting Schedule:
Contact Coordinator
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Meeting Schedule:
Thursday (1st and 3rd)
11:45 – 1:15 MST
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Launching Soon
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Meeting Schedule:
Tuesday (Frequency TBD)
2:00 MT
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Meeting Schedule:
Contact Coordinator
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Meeting Schedule:
Contact Coordinator
Request More Info
Meeting Schedule:
Contact Coordinator
Request More Info
Launching Soon
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Launching Soon
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Launching Soon
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×
University of Missouri ECHO Autism Clinic Sign Up Form
* CHOOSE A PROGRAM TO ATTEND
* Echo Autism Programs
Primary CarePsychologySchool PsychologySchool SupportTransition to
adulthoodCrisis CareDevelopment & SupportBehavior Analysis
* YOUR INFORMATION
* Name of Organization*
* Phone*
* Organization's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal
Code
AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua
and
BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire,
Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet
IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina
FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African
RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo,
Democratic Republic of theCook IslandsCosta
RicaCroatiaCubaCuraçaoCyprusCzechiaCôte
d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl
SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe
IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern
TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard
Island and McDonald IslandsHoly SeeHondurasHong
KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of
ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea,
Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's
Democratic
RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall
IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew
CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth
MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State
ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto
RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena,
Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint
MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan
MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra
LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth
AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri
LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab
RepublicTaiwanTajikistanTanzania, the United Republic
ofThailandTimor-LesteTogoTokelauTongaTrinidad and
TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor
Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited
StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin
Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands
Country
* Participant's Name*
First Last
* Phone*
* Email*
* Job Title*
* Credentials*
* Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal
Code
AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua
and
BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire,
Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet
IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina
FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African
RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo,
Democratic Republic of theCook IslandsCosta
RicaCroatiaCubaCuraçaoCyprusCzechiaCôte
d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl
SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe
IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern
TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard
Island and McDonald IslandsHoly SeeHondurasHong
KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of
ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea,
Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's
Democratic
RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall
IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew
CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth
MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State
ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto
RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena,
Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint
MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan
MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra
LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth
AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri
LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab
RepublicTaiwanTajikistanTanzania, the United Republic
ofThailandTimor-LesteTogoTokelauTongaTrinidad and
TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor
Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited
StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin
Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands
Country
* Please select which device(s) you will be using to participate in ECHO
Autism:*
* Tablet (iPad or Surface)
* Laptop/Desktop computer
* Polycom device
* Please check the box below to confirm your acknowledgement and consent to
participate as a community partner for the ECHO Autism project. I agree to:*
I agree to the terms below
Participate collegially in regularly scheduled ECHO Autism conferences by
presenting cases, providing comments and asking questions; Provide clinical
updates and de-identified outcome data on patients as needed; Keep
confidential any patient information provided by other community partners
during a conference; Complete periodic surveys to help improve services to
clinicians and other partners; Use required software including, but not
limited to Zoom and Box; Be solely responsible for the treatment of your
patients and understand that all clinical decisions rest with you regardless
of recommendations provided by other ECHO Autism participants and; Ensure
that your patients are aware of your participation in ECHO Autism and their
de-identified information could be shared. Be photographed and recorded
during ECHO Autism sessions.
Δ
×
Notifications