Referral Registration Form



If you are an audiologist who tests for auditory processing disorders or you are another professional who otherwise works with individuals affected by auditory processing disorders and you would like to be listed in the national referral program, please fill out the registration form below.  Although there is no fee to join the National Referral Program, you are encouraged to support the NCAPD by becoming a member of the organization.

Name & Credentials 

Office Name 

Street Address 


State  Zip 

Country (if other than US) 

Phone      Fax 

Email      Website 

Additional Comments 

By submitting this form, I hereby give the NCAPD permission to list the above information in their National Referral Program.  I understand that the above information will be listed on the NCAPD web site and that it  may also be distributed in written form to individuals seeking referrals from the NCAPD.  I agree not to hold the NCAPD responsible for any contacts that may result as a result of being listed in the National Referral Program.  I also understand that I may withdraw my name from the National Referral Program at any time by contacting the NCAPD in writing.