Gravity Forms to Google Sheets - Levels OPT™ Specialist Application Name(Required) First Last Email(Required) Organization/Therapy Practice Name Profession Speech Language Pathologist/Therapist Behavioral Therapist/ABA Therapist Occupational Therapist Teacher Myofunctional Therapist/COM Feeding Therapist/Specialist select all that applyIf profession is not listed above, please provide here Address(Required) Street Address Address Line 2 City State / Province / Region AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Are you a Level 3 OPT Specialist and interested in pursuing Level 4 Advanced Specialist Training? Yes No Level 1 -- LEARNING OPT™LEVEL 1 course requirements: please select the courses you have completed (if you have not taken these courses, leave unchecked) 3-Part Treatment Plan for OPT™ (Oral Placement Therapy) -- the foundations for OPT OPT™ Assessment and Treatment Plan -- once you've learned the fundamentals in 3-Part Treatment Plan for OPT, it's time to begin building your preliminary OPT Plans Provide LEVEL 1 course names completed and dates of completion Verify that you have met Level 1 requirements (False verification may result in automatic expulsion from this training program(Required) Yes, I verify that I HAVE COMPLETED Level 1 course requirements and have applied the OPT techniques for at least 6 months No, I HAVE NOT COMPLETED Level 1 requirements but I'm planning to this year No, I have not met Level 1 requirements LEVEL 2 -- EXPANDING YOUR KNOWLEDGE AND PRACTICERequirements: Complete LEVEL 1 coursework + 6 months (minimum) applied or observed OPT techniques in your practice (depending upon your professional role on your team). Also required: completion of at least one of our core courses + completion of at least 6 additional hours of TalkTools coursesLEVEL 2 CORE COURSES: Have you taken at least ONE of the following courses? Feeding Therapy: A Sensory Motor Approach Superpowers of the Sensory System Motor Speech Disorders OR Sensory Motor Approach to Apraxia Kaleidoscope Model for Feeding Feeding Disorders: Focus on Dysphagia Best Practices in Feeding, Speech and Mouth Function Assessment and Remediation of Tethered Oral Tissues Taking Your Clients with Autism from Non-Vocal to Verbal Eating and Swallowing: A Global Approach Provide CORE COURSE names completed and dates of completion 12 hours of additional can include: additional Level 2 core courses taken, a non-core 12-hour course or a combination of shorter courses to equal a total 12 hours LEVEL 2 ADDITIONAL COURSES: Have you taken AT LEAST 6 hours of additional, elective TalkTools courses (in the last 3 years)(Required) I verify that I HAVE COMPLETED 6 HOURS of additional TalkTools courses in the last 3 years I HAVE NOT COMPLETED 6 HOURS of additional TalkTools courses in the last 3 years Provide ADDITIONAL COURSE name(s) and dates of completion 12 hours of additional can include: additional Level 2 core courses taken, a non-core 12-hour course or a combination of shorter courses to equal a total 12 hours Verify that you have met Level 2 requirements (False verification may result in automatic expulsion from this training program(Required) Yes, I verify that I have completed Level 2 course requirements and have applied the OPT techniques for at least 6 months No, I have not met Level 2 requirements but I'm planning to this year No, I have not met Level 2 requirements LEVEL 3 -- OPT™ SPECIALISTThe Level 3 Training Program is a 2-day, interactive workshop limited to a small group of speech and feeding professionals who have completed Level 1 and Level 2. Candidates will work closely with the Instructor, who will provide case studies and guide discussion on OPT™ evaluation and treatment strategies. Admission to Level 3 Training includes: submission of this application, completion of Level 1 coursework, completion of Level 2 coursework, 1 year of applied or observed techniques (depending upon your professional role on your team) + successful completion of the qualifying pre-test and interview.Provide verification of your professional credentials (license, government certification)Max. file size: 256 MB.Have you ever been denied a professional license and/or certificate or have you have had your license revoked, canceled or suspended?(Required) Yes No If you answered "yes" to the above question, provide the type of license/certification, name and address of issuing agency and reason for denial or revocationHave you had disciplinary proceedings initiated against you in your current state, governing jurisdiction, province or country where you are practicing?(Required) Yes No If you answered "yes" to the above question, provide state, governing jurisdiction, province, country, and the date of proceeding and outcomeHave you voluntarily surrended any professional certificate, license or other professional verification?e you are practicing?(Required) Yes No Please provide a pdf of your current resumeMax. file size: 256 MB.LEVEL 4 -- OPT™ ADVANCED SPECIALISTThe Level 4 Training Program is a multi-day workshop, limited to a small group of Level 3 OPT™ Specialists. Learners will provide their own OPT™ case studies and, together with the Instructor, will lead interactive, collaborative discussions on how to build a comprehensive OPT™ Program. Acceptance to the Level 4 Training includes: submission of this application, completion of Level 1 coursework, completion of Level 2 coursework + completed of Level 3 Training + 2 years of applied or observed techniques (depending upon your professional role on your team) + successful completion of the qualifying pre-test and interview.What was the start date of your Level 3 TrainingMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202020212022202320242025What was the end date of your Level 3 TrainingMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202020212022202320242025Is your professional license/certification that we have on file from your Level 3 training current and valid? Yes No Have you had disciplinary proceedings initiated against you in your current state, governing jurisdiction, province or country where you are practicing since qualifying as a Level 3 OPT Specialist? Yes No If you answered "yes" to the above question, provide state, governing jurisdiction, province, country, and the date of proceeding and outcomeHas anything change on your resume since you applied for Level 3 Training? If so, please provide a pdf of your current resumeMax. file size: 256 MB.ADDITIONAL COMMENTSAny additional information you would like to add?
