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(*)

Address 2 (*)

Weblink (*)

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

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.

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 to finalize your membership. Please have your references complete the attachedReference Checking form and submit to us directly at: brad@integrativechange.com.

Terms & Conditions(*)

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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