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Membership Application
  1. Integrative Change screens and pre-qualifies all of its members. Please complete the following application and review all the Membership Benefits and Agreements.
  2. You are applying as an (*)
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  3. Contact Details

  4. E-Mail Address(*)
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  5. Full Name(*)
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  6. LicenseNumber
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  7. OfficeAddress(*)
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  8. For New York applicants, what area is your office?
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  9. Office Phone(*)
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  10. Office Fax(*)
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  11. Cell Phone(*)
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  12. Website Address(*)
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  13. Years in Practice(*)
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  14. Insurance Accepted(*)
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  15. LiabilityInsurance(*)
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  16. Which clinical category are you applying for? (First Choice) (*)
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  17. 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:"(*)
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  18. Which clinical category are you applying for? (Second Choice) (*)
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  19. Which clinical category are you applying for? (Third Choice) (*)
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  20. What advanced training/experience do you have in the above categories? What evidenced-based practices (e.g. CBT) do you use?(*)
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  21. TELL US ABOUT YOURSELF

  22. What professional accomplishments are you proud of?
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  23. What current projects are you working on?
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  24. What are your long-term professional goals?






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  25. If you select "Other", please list them here.
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  26. Profile

  27. Training Topics for which you are willing to provide CEU trainings:(*)
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  28. Are you willing to regularly:(*)
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  29. Has a complaint or legal action ever been filed against you regarding your practice? (*)
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  30. If so, please explain:
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  31. Are you interested in attending any professional networking events?(*)
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  32. Please provide a brief description of your services and a Bio. This description should focus on the first category for which you are applying (e.g. Couples Counseling).(*)
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  33. Please provide the name/contact info any other mental health or health practitioners who you believe would be interested in the Integrative Change Network:(*)
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  34. Pllease 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.
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  35. TELL US ABOUT YOUR BUSINESS

  36. Select the following business services which you believe will help improve your practice:










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  37. If you select "Other", please list them here.
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  38. Which clinical areas do you not treat for which you typically refer patients out?(*)
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  39. What specific types of professionals (e.g. Pediatrician) are good referral sources for you?
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  40. What professional organizations do you currently belong to?
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  41. References

  42. Please tell us who referred you to Integrative Change:
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  43. Two professional references are required. Please have your references complete the attached Reference Checking form and submit to us directly at: brad@integrativechange.com.
  44. Terms & Conditions(*)
    You must accept our terms and conditions to be part of the program.

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