Membership Application

Integrative Change screens and pre-qualifies all of its members. Please complete the following application and review all the Membership Benefits and Agreements.

You are applying as an (*)

Contact Details

E-Mail Address(*)

Full Name(*)

License Name and Number

OfficeAddress(*)

For New York applicants, what area is your office?

Office Phone(*)

Office Fax(*)

Cell Phone(*)

Website Address(*)

Years in Practice(*)

Insurance Accepted(*)

Specify Insurance Carrier(s) that you accept:

LiabilityInsurance(*)

Which clinical category are you applying for? (First Choice) (*)

If you do not see the category for which you are applying, please list it here and Integrative Change will possibly create this category for you:"(*)

Which clinical category are you applying for? (Second Choice) (*)

Which clinical category are you applying for? (Third Choice) (*)

Company(*)

City(*)

State(*)

Zip code(*)

Country (*)

Title(*)

Location (*)

Address 2 (*)

Weblink (*)

Contact Details(*)

What advanced training/experience do you have in the above categories? What evidenced-based practices (e.g. CBT) do you use?(*)

TELL US ABOUT YOURSELF

CORE VALUES

Integrative Change has five core values: an integrative approach to healthcare, community, helpers reward, clinical expertise, and professional development. Please be specific about how you will fit these core values.

1. How is being part of a community of practitioners important to you?

2. How are you willing to help other members?

3. Are you willing to invite guests to meetings and/or encourage others to join Integrative Change?

4. How do you take an integrative approach in your practice (e.g. combining various techniques, coordinate treatment with multiple practitioners)?

5. In what ways do you want to grow professionally?

6. What professional accomplishments are you proud of?

7. What current projects are you working on?

8. What are your year-end professional goals?

If you select "Other", please list them here.

Profile

Has a complaint or legal action ever been filed against you regarding your practice? (*)

If so, please explain:

Has your professional license ever been suspended or revoked?

If yes, please explain why.

Provide a description of your services related to the category for which you are applying (e.g. Couples Therapy). Note: this will be used in creating your profile on our practitioner directory so be sure to provide complete information. (*)

Provide your Bio. This should include your educational background and any advanced training you have received, especially as it relates to the category for which you are applying.

Please provide the name/contact info any other health (medical, mental health, or alternative health) practitioner who you believe would be interested in the Integrative Change Network:(*)

Please provide a professional headshot or your company logo. The file should be not wider than 300 pixels. Please resize the image before attaching it to this application.

TELL US ABOUT YOUR BUSINESS

Integrative Change has relationships with several Affiliate Partners (AP) who provide excellent business services for health and wellness professionals. Select the following business services which you believe will help improve your practice:

If you select "Other", please list them here.

Yes, please have the AP contact me with more information about their services. I prefer to be contacted via:

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Which clinical areas do you not treat for which you typically refer patients out?(*)
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What specific types of professionals (e.g. Pediatrician) are good referral sources for you?
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What professional organizations do you currently belong to?

References

Please tell us who referred you to Integrative Change:
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Two professional references are required. Please have your references complete the attached Reference Checking form and submit to us directly at: brad@integrativechange.com.

As an IC member, you are expected to attend 100% of the meetings. If you are unable to attend, you are expected to find a substitute (e.g. colleague, office manager, etc.) so that your services are represented in every meeting. Are you committed to this agreement?

Terms & Conditions(*)
You must accept our terms and conditions to be part of the program.

1. I agree to complete the New Member Orientation (a dial-in phone conference, approximately 20 minutes)
2. I agree to attend the quarterly networking meetings and to find a substitute if I cannot attend

Please print the contents of this application BEFORE hitting submit. This is to protect all this data in case of a transmission error.

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