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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.

Contact Details

E-Mail Address(*)

Full Name(*)

License Name and Number(*)


Office Phone(*)

Cell Phone(*)

Website Address(*)


Years in Practice(*)

Insurance Accepted(*)

Specify Insurance Carrier(s) that you accept(*)

Liability Insurance(*)

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)(*)




Zip code(*)

Country (*)


Location (*)

Contact Details(*)



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

If so, please explain:

Provide a 1-2 paragraph description of your services. This description must be related to the specific category for which you are applying (e.g. Couples Therapy). This description will be used for your website profile, so please make sure this is completed.(*)

Bio: Provide 1-2 paragraphs. 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 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(*)


Select the following business services which you think will help improve your business. Integrative Change has relationships with several businesses who provide excellent services for health and wellness professionals. You will not be solicited for business by them:

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

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

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


Please tell us who referred you to Integrative Change:

Two professional references are required to finalize your membership. Please have your references complete the attached Reference Checking form and submit to us directly at:

Terms & Conditions (*)

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