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Referral List Submission

Are you a neurodiversity-affirming business or individual? Submit the form below to be listed on our resources page!

Our Referral List

Please fill out the form below to be listed on our referral/resources page

Name

Pronouns

Buisness/Organization Name

Email

Licensure

I am a... (Choose the best category) *

Therapist, Counselor, Social Worker

Neurodivergent Coach

Psychiatrist, Mental Health Medication Management Provider

SLP, OT

Doctor, RN, Medical Provider

Non-mental health related business serving neurodivergent individuals

Non-profit organization serving neurodivergent individuals

Website

Phone Number

Locations Served

Population Focus. Check all that apply:

Children

Teens

Adults

ADHDers

Autists

PDA

OCDer

Gifted/2e

Personality Disorders

Dissociative Disorders

PTSD/CPTSD/Trauma

LGBTQ+

BIPOC/PoGM

Diverse Relationship Structures

Kink/BDSM

Other

Type of Offerings. Check all that apply:

Individual Therapy

Relationship Therapy

Group Therapy

Medication Management

Diagnostic Assessments

Non-Diagnostic Assessments

Case Management

WAPTH Letters

Accomodation Letters

ESA Letters

Telehealth

In-Person

Payment Options:

Private Pay

Sliding Scale

Grant Funded

Medicaid

Aetna

Anthem/BCBS

Beacon

Carelon

CHP+ (Child Health Plan Plus)

Cigna

Kaiser

TriCare

United Healthcare/UMR/Optum

Other

Specialty/Description of Practice and/or Business?

Relevant Identities You'd Like to Disclose

Fee Structure

I confirm that I am neurodiversity-affirming and mention this on my website or practice page *

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