Professional Network Form

Please select any of the following options that apply to you:

Occupational therapist
Speech/Language therapist
Psychiatrist/Psychologist/Psychotherapist
Educational support
Learning and family support
Other (please describe below)
       (e.g. support group/babysitting/respite care)

Please provide the following information  (please only provide details relevant to the services you are offering here):

First name
Last name
Title
Profession
Professional qualification(s)
Organisation/ practice name
Are your services recognised by the Dutch health authorities	Yes   No
Street address
Address (cont.)
Postcode
Town/City
Daytime Phone
Evening Phone
Fax
EMail*
Website address (if appropriate)

*Please make sure you supply a valid EMail address,
otherwise your form will not be sent or processed correctly.

Please summarise below the services you are offering or, in the case of non-practitioners, your reason for participating in this network  (e.g. offering babysitting services or respite care).  Please include specialisms and age range serviced.  (We would ask you to limit your summary to 60 words or less, and to avoid acronyms if possible.)

If you are offering your services, please advise if you have a waiting list, and if so, approximately for how long:

Are you happy for all the above details to appear on the AAOF website?

Yes    No  (If no, please explain in Comments box below)

Please add below any other comments you wish to make (these will not be published on the website):

Finally, please let us know below whether you would also like to be added to our mailing list.

Yes, please add my details to the AAOF mailing list
No, please do not add my name to your mailing list

 

Please make sure your above details are correct
(especially your EMail address),
then press the 'Send to AAOF' button below. 

We will add your details as soon as possible, or we will contact you for further information in the case of any queries.