Request for Information from The Physical Health Services Directory

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Name of person or agency/organization requesting information

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Address to which to mail the response

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City, State and Zip

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Phone Number

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E-mail Address

Towns or cities to which you would travel for the services:

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Check the area(s) of expertise which you are interested in finding:

__ Children who have been adopted
__ Adopted internationally
__ Reading preplacement profiles
__ Adopted U.S. infant
__ Adopted U.S. older/waiting
__ Children in foster care
__ Children post foster care
__ Kinship/Guardianship families

__ ADD/ADHD
__ Addiction problems
__ Anxiety
__ Autism
__ Depression
__ Developmental delays
__ Eating disorders
__ FAE/FAS
__ HIV/AIDS

__ Language disabilities
__ Learning disabilities
__ Post-institutionalization
__ Post-traumatic stress
__ Ritualistic abuse
__ Sensory integration
__ Sexual abuse
__ Substance abuse
__ Tactile defensiveness
__ Other (please describe)
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Looking for a: ___ MD/DO ___DDS/DMD ___ Psychiatrist ___ P.T. ___ O.T.
___ Speech/Language Therapist ___ Massage Therapist
Other, specifically ______________________________

Please enclose $5.00-ACONE Members or $25.00-Non-members to Adoption Community of New England, Inc. to cover the processing and mailing of this request. Information on up to seven professionals will be sent as a response. If more than seven professionals fit your request profile, the profiles of the seven closest to you geographically will be sent. If the professionals who fit your request profile do not meet your needs in other ways, you may request information on the others who fit your request profile at no additional fee.

Mail payment to: ACONE, Inc., 45 Lyman Street #2, Westborough, MA 01581

Requests charged on MasterCard, Visa or Discover may be faxed to us at 508.366.6813.

#_______________________________Exp. _______

3 digit # on back of card _______

Name and billing address (if different from above):

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