NeuroTransform Referral Network Application

NeuroTransform Referral Network Application

Apply to join the NeuroTransform Referral Network as a coach or practitioner.
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.
Contact & Practice Details

Please provide your contact and practice information.
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
Training, Credentials, and Guided Imagery

Share your professional background and relevant training.
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.

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Areas of Focus and Client Fit

Tell us about your preferred client populations and focus areas.
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.).
Values and Scope of Practice

Share your approach to client care and professional boundaries.
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?
Practical Details

Help us understand your availability and practical considerations.
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?
Consent to Be Considered

Please confirm your application details below.
Required

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. I am responsible for working within my own scope of practice, maintaining appropriate credentials/insurance where applicable, and complying with all laws and professional standards relevant to my services.
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.
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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