Practitioner Application

Practitioner Application
Thank you for inquiring about becoming a Practitioner.

Please complete the application below and submit it for review by our council.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Let's Get to Know You
How Long Have You Been Practicing Energy Medicine?*

0 - 1 year1 - 5 years5+ years
List All Modalities You're Certified In and If You're Planning to Practice them at COJ*
Do you have a wbsite?*
Website Address
Do You Have Liability Insurance?*
Are You Open to Walk In Clients?*
Do You Plan to work with Existing Clients at Circles of Joy?*
Are You Open to New Clients?*
How Frequently Will You Practice at the Center?*
Are You Open to Committing to:*

6 months at the Center12 Months at the Center2 Years at the CenterOver 2 Years at the Center
What Attracted You to Circles of Joy?*
Should be Empty:

Thank you for inquiring about becoming a Practitioner.