[memb_registration_form autologin="yes" tagids="210, 212" success_url="https://echoautism.org/start-an-echo/"]
First Name
Last Name
Email
Phone Number
Company
Organization address (personal address if not affiliated with an organization)
Password
Which of these fields best categorizes the field you work in?
Clinical Intervention (ABA, OT, SLP, etc.)
Community Support/ Resource Navigation/ Community Resource
Education
Family Advocate/Self-Advocate
Clinical Health/Allied Health
Law
Mental Health
Non-Clinical Health/ Public Health/ Research
Nursing
Nurse Practitioner
Oral Health
Pharmacy
Physician
Physician Assistant
Psychologist
Social Work
Student
Other
What is your role in that field?
Behavioral Implementer
Behavioral Specialist
Dietician
Occupational Therapist
Occupational Therapist Assistant
Physical Therapist
Physical Therapist Assitant
Speech Language Pathologist
Speech Language Pathologist - Assistant
Other
What credentials do you have relating to your field of work?
BCaBA
BCBA
BCBA-D
LBA
LABA
RBT
LD
OTR/L
COTA/L
PT
PTA
CCC-SLP
SLPA
Other
What is your role in that field?
Certified Peer Mentor
Community Health Worker
Family Advocate
Family/Caregiver/Patient Navigator
Program Coordinator/Manager/Supervisor
Resource Specialist/Resource Navigator
Support Coordinator/Service Coordinator
Other
What is your role in that field?
Certified Peer Mentor
Higher Education (non-medical): Professor/Assistant Prof/Associate Prof/Adjunct Prof/Emeritus, etc.
Para Professional
School Administrator
School Principal
School Teacher
Other
Please provide your credentials related to this field of work
Please select if you have lived experience in the following areas:
Parent or caregiver of a child or person with autism or other developmental or intellectual disability
Person with autism/ Autistic person
What is your role in that field?
Caregiver
Certified Peer Mentor
Extended Family / Caregiver Support
Family Advocate
Foster Parent
Grandparent
Guardian
Kinship Foster Parent
Parent
Parent Partner
Self-Advocate
Other
None
What is your role in that field?
Clinical Lab Worker/ Med Technologist
Electroneurodiagnostic Technologist
EMT/ 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
What is your role in that field?
Law Student
Attorney
Guardian ad litem
Judge
What is your role in that field?
Case worker
Clinician/Therapist/Counselor
Community Support Specialist
Provisional Clinician/Therapist/Counselor
Other
Behavioral Credentials
BCaBA
BCBA
BCBA-D
LBA
LABA
Other
None
Counseling or Therapy Credentials
LPC
LPCC
PLPC
LCMFT
LMFT
Other
None
Social Work Credentials
LAMSW
LBSW
LCSW
LMSW
Other
None
Certifications or Licenses in Substance Abuse and Addiction Credentials
What is your role in that field?
Biostatistician
Quality Assurance/Compliance
Researcher/Analyst
Other
What credentials do you have relating to your field of work?
BME
CCRC
CEHT
CHC
CHCP
CHES
CPHQ
CPHRM
MCHES
PCMH CCE
REHS
REHS/RS
Other
What is your role in that field?
Nurse
Nurse Aide
What credentials do you have relating to your field of work?
CNA
LPN
LVN
RN
Other
What is your role in that field?
Family Medicine
Internal Medicine - General
Internal Medicine-Pediatrics (Med-Peds)
Internal Medicine - Specialist
Neurology
Nurse Practitioner
Pediatrics - General
Pediatrics - Specialist
Psychiatry - General
Psychiatry - Child and Adolescent
Physician Assistant
Other
What credentials do you have relating to your field of work?
ACCNS
ANP
APN
APRN
APRN-BC
BC FNP
C-FNP
CNL
CNS
CPNP/CPNP-PC
CS
FNP/FNP-BC/FNP-C
NP/NP-C
PA-C
P/MHNP/PHNP-CNS/PMHNP-BC
PMHS
PNP/PNP-BC/RNC-FNP
Other
What is your role in that field?
Dentist
Dental Hygienist
Dental Assistant
What credentials do you have relating to your field of work?
RDH
DDS
DMD
Other
What is your role in that field?
Pharmacist
Pharmacy Technician
What credentials do you have relating to your field of work?
AAHIVP
BCACP
BCPP
BCPS
CPhT
CSP
Other
What is your role in that field?
Family Medicine
Internal Medicine - General
Internal Medicine-Pediatrics (Med-Peds)
Internal Medicine - Specialist
Neurology
Nurse Practitioner
Pediatrics - General
Pediatrics - Specialist
Psychiatry - General
Psychiatry - Child and Adolescent
Other
What credentials do you have relating to your field of work?
BCFM
FAAFP
FAAP
FACS
FAPA
DO
MBBS
MBchB
MD
Other
What is your role in that field?
Family Medicine
Internal Medicine - General
Internal Medicine-Pediatrics (Med-Peds)
Internal Medicine - Specialist
Neurology
Nurse Practitioner
Pediatrics - General
Pediatrics - Specialist
Psychiatry - General
Psychiatry - Child and Adolescent
Other
What credentials do you have relating to your field of work?
PA
PA-C
Other
What is your role in that field?
Psychology - Clinical
Psychology - Counseling
Psychology - Neuro
Psychology - School
Other
What credentials do you have relating to your field of work?
ABCN
ABPP
LP
LPA
LSSP
Other
What is your role in that field?
Case Manager/Coordinator
Clinician/Therapist/Counselor
Supervisor
Other
Social Work Credentials?
LAMSW
LBSW
LCSW
LMSW
Other
Behavioral Credentials
BCaBA
BCBA
BCBA-D
LBA
LABA
Other
None
Counseling or Therapy Credentials
LPC
LPCC
PLPC
LCMFT
LMFT
Other
None
What is your role in that field?
Intern/In-training
Student - Undergraduate Study
Student- Graduate Study
Student - Post-graduate Study
Student - Medical
Student- Medical Resident
Other
Area of Study?
Highest Level of Education
High School
Associates
Bachelors
Masters
Doctorate
Associates
AND
ASN
AA/AAS/ADP
Other
Bachelors
BA/BS
BS Ed
BSN
BSW
MBBS
MBchB
Other
Masters
MS
MBA
MDiv
MEd
MHA
MPA
MPAS
MPH
MSMI
MSN
MSW/MSSW
MOT
MPT
Other
Doctorate
DPT
DO
DNP
DNP-c
DHSc
DrPH
EdD
EDS
MD
OTD
PhD
PsyD
Other