1. Application for RDI Program Certification

I. Personal Data:

Tell us about yourself
This information is used for all offical records so please be accurate and use full legal name.
Full Name*

PrefixFirst NameMiddle NameLast NameSuffix
Phone No. :*
Mobile No.. :
Other No.. :
E-mail :*
Where the confirmation will be sent to
Home Address :*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

II. Education

List all colleges/universities attended
College/University*
Attendance Dates (MO/YR -MO/YR)*
Major*
Minor
Degree/Certificate*
Completion Date (MO/YR)*
Education Cont.
College/University
Attendance Dates (MO/YR -MO/YR)
Major
Minor
Degree/Certificate
Completion Date (MO/YR)
Education Cont.
College/University
Attendance Dates (MO/YR -MO/YR)
Major
Minor
Degree/Certificate
Completion Date (MO/YR)

III. Work Experience

List all work experience
Job Title*
Setting and Major Duties*
Dates (MO/YR-MO/YR)*
Work Experience Cont.
Job Title
Setting and Major Duties
Dates (MO/YR-MO/YR)
Work Experience Cont.
Job Title
Setting and Major Duties
Dates (MO/YR-MO/YR)

IV. Volunteer Experience

List all your volunteer experience
Organization*
Volunteer Duties and Accomplishments*
Dates (MO/YR-MO/YR)*
# Hours /WK, MO or YR*
Volunteer Experience Cont.
Organization
Volunteer Duties and Accomplishments
Dates (MO/YR-MO/YR)
# Hours /WK, MO or YR
Volunteer Experience Cont.
Organization
Volunteer Duties and Accomplishments
Dates (MO/YR-MO/YR)
# Hours /WK, MO or YR

V. Written Essay Questions

Type a concise essay for each question below
Have you attended an RDI® workshop or have you read The RDI® Book by Dr. Steve Gutstein? If so, what parts of these did you find most insightful?
Answer Question Below*
Do you have a dual role? Are you a professional as well as a parent of a child on the Autism Spectrum? If applicable, what is your child's age and have you started an RDI® Program with him/her? If so, which consultant are you working with and how long have you been working with him/her?
Answer Question Below*

VI. Written Essay Questions Cont.

Type a concise essay for each question below
A) Describe your experience(s) working with children with autism. Include the setting, your role, the nature and age of the children involved and then summarize your feelings about the experience(s).

**NOTE** If you do not have any experience working with children with autism, answer the following question instead:

B) Describe your experience(s) volunteering with children in general. Include the setting, your role, the nature and age of the children involved and then summarize your feelings about the experience(s)
Answer Question Below*
As part of certification, you are required to work with two families who have a child formally diagnosed with an Autism Spectrum Disorder. Without including any identifying information about the families, please explain the family dynamics of both families you are thinking of using for supervision. Please note that while you must stay with the same families throughout supervision, you are not bound to use the specific families you describe here.

**Note** If you do not have these families yet please place N/A in the box below**
Answer Question Below*

VII. Video Essay Quesions
Record yourself answering the following questions. Upload the video to YouTube and place the link in the below section.
Question One

Why have you decided to go through the RDI® Certification Program? Describe how you see RDI® certification fitting into your current job or work setting. If you are not currently working, describe how you see yourself using your RDI® certification.
Question Two (Choose One)

1. Describe the "autism culture" in your area and how you feel about it. How do you see yourself contributing to that culture?

2. Describe why you have chosen to work with individuals diagnosed with autism?
Read and Understand the instructions.*

Yes, I have
Video Link 1*
Video Link 2*

VIII. Professional References
These professionals should be able to endorse your ability to function as a professional in the autism community. If you are a parent of a child on the spectrum, your first reference must be from the RDI® Consultant who is currently working with your family.
Reference I.
Full Name *

First NameLast Name
Profession/Title*
Relationship to Applicant*
E-mail*
Phone Number*
Reference II.
Full Name

First NameLast Name
Profession/Title
Relationship to Applicant
E-mail
Phone Number
Reference III.
Full Name

First NameLast Name
Profession/Title
Relationship to Applicant
E-mail
Phone Number

IX. Letter of Recommendation

This letter must be written by one of the applicant's references.
Please upload your letter of recommendation here:
Upload file
Letters of Recommendation must include the following:

1. Applicant's Name

2. Name of person writing letter

3. How long person has known applicant

4. Describe the applicant's strengths. Consider how these strengths will help him/her as an RDI® Consultant.

5. Describe the applicant's obstacles. Consider how these obstacles may impact the applicant's growth as an Consultant and how he/she may address them.

If the Applicant is a parent of a child on the spectrum, this letter of recommendation must be from his/her RDI® Program Consultant. The consultant's letter must include the items above as well as the following:

Consultant must affirm:

• This applicant and spouse have met regularly (every two weeks) with the consultant over the last six months.

• This applicant and spouse have progressed through the Family Consultation Program in a way that shows:

o They understand the mission and design of the program

o They have become good apprentices themselves

o They have successfully addressed any parent obstacles that would impede becoming a good guide

• This applicant and spouse have maintained a subscription on the RDI Learning community and consistently use the tools and resources found there for their work n the FCP

X. Background Check/Additional Information
In order to complete the application process, a background check must be completed by all applicants. Please enter the following information and follow the instruction provided to authorize and proceed with a background check.
In order to complete the application process, a background check must be completed by all applicants. Please enter the following information and follow the instruction provided to authorize and proceed with a background check.
Social Security Number*
(If you are an international applicant please type N/A)
Driver's License Number
(e.g. 123456789)
State Issued
Date of Birth*

MonthDayYear
As a requirement of the background check being conducted on you by PreCheck, you must complete a release form. Signing this form gives PreCheck permission to obtain information about you from agencies that maintain records.

Please follow these steps for the background check release form:

1. Click here to download a copy of the background consent form

2. Fill out the entire form, entering as much information as possible.

3. Provide signature on the release form and attach the file to the application or email it to Professionals@rdiconnect.com
Upload background check form here

XI. Additional Information
Has your license ever been suspended?*

NoYes (if yes, please explain below)
(if yes, please explain)
Have you been accused of improper conduct with a child/teenager/adult or client in any setting?*

NoYes (if yes, please explain below)
(if yes, please explain)
Have you been fired or asked to resign employment for improper conduct of any nature?*

NoYes (if yes, please explain below)
(if yes, please explain)

XII. Payment Information
There is a $50 USD non-refundable processing fee to apply to the Professional Certification Program regardless of acceptance. (US Training Center applicants only, all others please contact your RDI Training Center for information on payment)

Payment must accompany the application. Applications without the processing fee will not be reviewed. If fee is being paid by a third party please indicate and provide information below. (US applicants only, all others please contact your RDI Training Center for Payment information)

Payment is only accepted via credit card. We do not accept checks.

XIII. Applicant's Signature
I affirm that the information I have provided on this application form is complete, accurate and true to the best of my knowledge. I understand that furnishing false information on any part of this application may result in removal of the certification program if accepted.

I am also authorizing the use of my credit card for the application fee and any other fees that may apply.
Please Type Full Name for E-Signature*
www.rdiconnect.com Phone 713-838-1362
Should be Empty:

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Application For RDI® Program Certification

I. Personal Data:

II. Education

III. Work Experience

IV. Volunteer Experience

V. Written Essay Questions

VI. Written Essay Questions Cont.

VII. Video Essay Quesions

VIII. Professional References

IX. Letter of Recommendation

X. Background Check/Additional Information

XI. Additional Information

XII. Payment Information

XIII. Applicant's Signature