Hearts Connected Affiliate Network Application Form

Thank you for your interest in joining our CCLS Hearts Connected Affiliate Network Directory!

Before you begin the application, we would like to ensure that you understand a few important points:

1) We strongly believe that we are better together and that it takes all of us working together to bring awareness to our communities about the magic of Child Life.

2) We believe that every family and child should have access to a Child Life Specialist in their community.

3) Marketing and awareness are a JOINT responsibility. It is important that you maintain an active online presence—educating, engaging, and sharing your services—to ensure that your network understands the support we offer together. Hearts Connected is not solely responsible for generating your patient or client volume.
Name:*

First NameLast Name
Business Name
Best Contact Number:*

Area CodePhone Number
YesNo
Business E-mail Address:
Business Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website URL:
Social Link (most used):
PeerFacebookWebsiteInstagramLinkedInEmailOther (please specify)
Other:
Business Information

Below is a list of information that we would like to collect regarding your business operations and structure to determine if you meet the basic requirements needed to be listed on our registry.

Not all questions/answers are requirements to be listed! Most questions are to gain an understanding of your current business structure.
Certified CCLSMaster's DegreeAt least 5 years of experience as a CCLSAt least 3 years of experience in a hospital setting
Currently a 1099, no business structureC CoreS CoreLLCHave an EIN numberHave a NPI numberBusiness registered in your home state
Active professional liability insuranceHave claimed CCLS service income in past tax returnsWill claim current year's CCLS service income in 2025 tax return.Provide virtual services and use software other than FaceTime.Currently have a HIPAA compliant documentation systemRequire your clients to complete a service consent form.Require your clients to complete a Financial agreement.Require your clients to complete a HIPAA consent form.
Have a physical business location where clients come to me.Provide services in person, in the client's homeProvide services in a facility, through my companyHave a business websiteHave a business emailHave a business phone number
Word of mouth ONLYWord of mouth and ...Facebook, personal pageFacebook, business pageInstagram, personal pageGoogleYelpPrint adsOutreach to referral sourcesPinterestYouTubeThreadsSearch Engine Optimization (SEO/Key word search)Marketing Firm/Paid marketing helpOther
I am currently working 32h or more/week, on average.I am currently working 20- 32h per week on average.I am currently working less than 20h/week on average.I am looking to increase my clients/patients and the hours I work.
I have read the two-page informational flyer in full and if selected, I agree to sign a formal agreement confirming that I agree to the requirements to be listed.
Do you have any questions or concerns that you haven't seen addressed?
Thank you for completing this form.

We will be in contact with you via email within 3 business days.

If the application meets our listing qualifications, we will schedule a brief Teams interview.

You will hear from us regardless!
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