Name *
 

Email *
 

Practice Area *
School Therapy
Hand Therapy
Home Health
Long Term Care
Ergonomics
Mental Health
Rehab/Hosp
Early Intervention
Pediatrics
Gerontology
Other (please list below)  

Other Practice Area (if not listed above)
 

I am willing to have a student contact me via e-mail to field occupational therapy related questions. *
Yes
No  

I am willing to have a student observe/shadow my occupational therapy treatments for 1 day. *
Yes
No  

I am willing to have a student observe/shadow my occupational therapy treatments for 2+ days. *
Yes
No  

I give my permission for ArizOTA to list my name and e-mail only under the Members Only, Mentor Connection section on the ArizOTA website at www.arizota.org *
Yes
No