Referral List

If you have completed the full Basic conference and would like to be added to the Therapist Referral list, please complete the form below and submit along with a copy of your conference certificate (required).  If you do not have a copy of your certificate, please request a copy from the host of the conference you attended.

Please note: Your information will be accessible online and provided to those requesting a referral in your area. Therefore, please make sure the contact information you include is the information you want to share with potential clients/patients.  (Referrals lists are updated quarterly.)

Name:*
Title/occupation:*
Organization:*
Phone number:*
E-mail:*
Website address:
Address:*
Date of Conference: (mm/yyyy)*
City of Conference:*
Advanced Courses: (if applicable)
Are you implementing the SOS Approach to Feeding program at your site?*
If yes, please rate how close you adhere to the SOS tenants and use the SOS Approach as taught in the course.*
Are you implementing any other feeding programs?*
If yes, please specify the program(s):
Type of therapy:*
What is the age range of children you see in your practice?*
List other health professionals working as part of your feeding group:*
Upload your conference certificates. (If you no longer have your certificate, please contact the conference host to request a replacement copy). *
Comments:
By checking the box below, I agree that the information I have provided is correct. to the best of my knowledge. Furthermore, I agree that my name and workplace contact details will be placed on a list for families and health providers looking for health care professionals implementing the SOS Approach to Feeding program. Please note: Toomey & Associates, Inc. reserves the right to decline or remove contacts from this list. *