Call Today for a Referral: 786.201.4543

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 (*)
Invalid Input

Contact Details

E-Mail Address(*)
Invalid Input

Full Name(*)
Invalid Input

LicenseNumber
Invalid Input

OfficeAddress(*)
Invalid Input

For New York applicants, what area is your office?
Invalid Input

Office Phone(*)
Invalid Input

Office Fax(*)
Invalid Input

Cell Phone(*)
Invalid Input

Website Address(*)
Invalid Input

Years in Practice(*)
Invalid Input

Insurance Accepted(*)
Invalid Input

LiabilityInsurance(*)
Invalid Input

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

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:"(*)
Invalid Input

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

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

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

TELL US ABOUT YOURSELF

What professional accomplishments are you proud of?
Invalid Input

What current projects are you working on?
Invalid Input

What are your long-term professional goals?

Invalid Input

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

Profile

Training Topics for which you are willing to provide CEU trainings:(*)
Invalid Input

Are you willing to regularly:(*)
Invalid Input

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

If so, please explain:
Invalid Input

Has your professional license ever been suspended or revoked?
Invalid Input

If yes, please explain why.
Invalid Input

Are you interested in attending any professional networking events?(*)
Invalid Input

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. (*)
Invalid Input

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.
Invalid Input

Please provide the name/contact info any other mental health or health practitioners who you believe would be interested in the Integrative Change Network:(*)
Invalid Input

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.
Invalid Input

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:

Invalid Input

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

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

Invalid Input

Which clinical areas do you not treat for which you typically refer patients out?(*)
Invalid Input

What specific types of professionals (e.g. Pediatrician) are good referral sources for you?
Invalid Input

What professional organizations do you currently belong to?
Invalid Input

References

Please tell us who referred you to Integrative Change:
Invalid Input

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

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

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


Invalid Input