Health Touch NC Practitioner Profile Form

Practitioner's Name

Name (as you would like it to appear; e.g. Mr. David Allen Greer Jr.)

PrefixFirst NameMiddle NameLast NameSuffix

Degree Abbreviations (as you would like them to appear after your name; e.g., LRMT, Ph.D., LCAS)

Title(s) (e.g., Licensed Massage and Bodywork Therapist, Reiki Master Teacher, etc.)

Practitioner's Contact Information

In this section, please provide only the contact information that you would like to make available to the public for your business. This section allows for adding information for up to 2 businesses of yours. If there are additional business of yours that you would like added to profile, please provide the information in the Comments section at the end of the form.

Business #1: Name*

Business #1: Email*

example@example.com

Business #1: Phone Number*

Please enter a valid phone number.

Business #1: Website

Business #1: Modalities*

Business #2: Name

Business #2: Email

example@example.com

Business #2: Phone Number

Please enter a valid phone number.

Business #2: Website

Business #2: Modalities

Services

In this section, please provide the name of each modality you offer, their respective category, and a brief description of the category. If you practice more than 4 modalities, please provide the information for the rest in the Comments section at the end of the form.

Category of Modality #1*

Body Therapy (e.g., deep tissue massage, acupuncture, reflexology, etc.)Energy Healing (e.g., Reiki, Polarity Therapy, crystal healing, etc.)Movement Therapy (e.g., physical therapy, yoga, Qigong, etc.)Plant Medicine (e.g., aromatherapy, herbalism, flower essence therapy etc.)Talk Therapy (e.g., health coaching, family counseling, psychotherapy, etc.)Other

Name of Modality #1*

Description of Modality #1*

Category of Modality #2

Body Therapy (e.g., deep tissue massage, acupuncture, reflexology, etc.)Energy Healing (e.g., Reiki, Polarity Therapy, crystal healing, etc.)Movement Therapy (e.g., physical therapy, yoga, Qigong, etc.)Plant Medicine (e.g., aromatherapy, herbalism, flower essence therapy etc.)Talk Therapy (e.g., health coaching, family counseling, psychotherapy, etc.)Other

Modality #2

Description of Modality #2

Category of Modality #3

Body Therapy (e.g., deep tissue massage, acupuncture, reflexology, etc.)Energy Healing (e.g., Reiki, Polarity Therapy, crystal healing, etc.)Movement Therapy (e.g., physical therapy, yoga, Qigong, etc.)Plant Medicine (e.g., aromatherapy, herbalism, flower essence therapy etc.)Talk Therapy (e.g., health coaching, family counseling, psychotherapy, etc.)Other

Modality #3

Description of Modality #3

Category of Modality #4

Body Therapy (e.g., deep tissue massage, acupuncture, reflexology, etc.)Energy Healing (e.g., Reiki, Polarity Therapy, crystal healing, etc.)Movement Therapy (e.g., physical therapy, yoga, Qigong, etc.)Plant Medicine (e.g., aromatherapy, herbalism, flower essence therapy etc.)Talk Therapy (e.g., health coaching, family counseling, psychotherapy, etc.)Other

Modality #4

Description of Modality #4

About the Practitioner (This information can include your biography, goals, work's inspiration, education background, etc.*

Comments:

Profile Picture

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Logo

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