NeuroTransform Referral Network Application

The NeuroTransform Referral Network connects clients with coaches and practitioners for educational, supportive, and integrative wellbeing services. NeuroTransform provides education and referrals only and does not provide medical care, psychotherapy, or crisis services. Clients referred through NeuroTransform are not entering a medical or psychotherapy relationship with NeuroTransform.

Full name

First NameLast Name

Pronouns

Email address

example@example.com

Phone number

Please enter a valid phone number.Format: (000) 000-0000.

Website or profile link

Practice name

Location (city, state/province, country)

Session format offered

Primary professional role(s) (e.g., Health Coach, Guided Imagery Practitioner, Therapist, Nurse, etc.)

Please list your relevant degrees and training (e.g., MA Integrative Health Studies, coaching certificates, somatic training).

Please describe any health-coaching training programs you have completed (including school/program names and dates).

NBHWC status

Have you completed specialized training or a certificate in guided or transformative imagery? If so, please describe the program(s) and year(s).

Do you currently hold any active professional licenses or regulated credentials relevant to your work? If yes, please list the license type, state/jurisdiction, and current status. If not applicable, please write N/A.

Optional: Upload supporting documents, such as coaching certificates, training certificates, CV/resume, proof of NBHWC status, or professional license documentation if applicable.

Which populations do you most love working with? (e.g., anxiety, burnout, life transitions, chronic illness, highly sensitive people, etc.)

List 3–5 key areas you focus on in your work (e.g., stress reduction, sleep, self-compassion, nervous system regulation, habit change).

Briefly describe the main approaches or modalities you use (e.g., integrative health coaching, guided imagery, mindfulness, somatic practices, parts work, etc.).

Typical session length and format (e.g., 50-minute Zoom sessions, 60-minute in-person sessions, packages, etc.).

How do you embody a client-centered, integrative, mind–body–spirit approach in your work?

How do you approach trauma awareness, cultural sensitivity, and inclusion in your sessions?

Please describe how you stay within your scope of practice and how you decide when to refer a client to a licensed medical or mental health professional.

How comfortable are you with introducing basic concepts of neuroplasticity and brain-based change to clients? Is this something you already talk about, or would you like brief guidance from NeuroTransform?

Do you currently have capacity to accept new clients from the NeuroTransform referral network? If yes, how many per month feels sustainable?

What time zone are you in, and what days/times do you typically see clients?

What is your typical fee range for individual sessions or packages?

Anything else you’d like NeuroTransform to know?

Required acknowledgments

I understand that inclusion in the NeuroTransform Referral Network, if accepted, does not create an employment, partnership, supervisory, medical, therapeutic, or clinical relationship with NeuroTransform. NeuroTransform does not supervise, employ, credential, control, or guarantee my services. I am solely responsible for working within my own scope of practice, maintaining appropriate professional liability insurance, and complying with all laws, licensing rules, professional ethics rules, advertising rules, privacy obligations, and referral-fee restrictions applicable to my profession, services, and jurisdiction. I will not accept referrals where doing so would violate those obligations.I understand that NeuroTransform provides wellness, educational, coaching-style, and guided imagery support only. NeuroTransform does not provide medical care, psychotherapy, diagnosis, treatment, crisis services, or emergency support. I will not submit urgent, crisis-related, diagnostic, or highly sensitive medical information through this form. If I am experiencing a medical or mental health emergency, thoughts of self-harm, or a crisis, I understand this form is not an appropriate contact method and I should call 911, 988, or seek immediate help from a qualified professional or emergency service. Information I submit will be used to review my application, communicate with me about the Referral Network, and otherwise administer my potential participation in the Network, consistent with the Privacy Policy.

This form is hosted by Jotform, a third-party form platform used by NeuroTransform to collect form submissions. Information you provide in this application will be used by NeuroTransform only to review your fit for the Referral Network and to contact you about your application. For more details, see our Privacy Policy.

NeuroTransform Referral Network Application

Contact & Practice Details

Training, Credentials, and Guided Imagery

Areas of Focus and Client Fit

Values and Scope of Practice

Practical Details

Consent to Be Considered