Clone of Qigong Clinical Practitioner Application Form

Qigong Senior Clinical Practitioner Application Form

Please review the entire application before beginning. This will help ensure you have all the information needed to complete each section. You may also scroll to the bottom of the form at any time to Save your progress and return later.
Contact Info

Please provide your current contact information so we may reach you regarding your application.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Qualifications

Please confirm that you meet the minimum requirements for this certification before continuing with the application.
1,500 hours of documented Formal Clinical Qigong Training*, with up to 600 hours permitted from regular Qigong training1,000 hours of providing Qigong treatments using Formal Clinical Qigong Training* healing methods.10 years of experience in a clinical setting providing Clinical Qigong services.
*Formal Clinical Qigong Training (FCQT)

The documented hours of study where direct instruction is received in an in-person class setting from an instructor. These hours include energetic anatomy & physiology, Qi transmission through non-touch and/or light touch methods and recommendation of Qigong exercises and meditations. This training teaches the development of skills, derived through formal instruction and self-cultivation, in the assessment, clearing and direct treatment of one’s physical, mental, emotional and spiritual (consciousness) alignment rooted in Taoism and Chinese medical principles. The clinical application of Qigong integrates Formal Qigong Training into clinical training and includes Chinese medical theory and Qigong history, theory, and philosophy. Other techniques and practices such as acupressure, cupping and adjunct therapies may also be taught. Curriculums vary between schools.
YesNo
Formal Clinical Qigong Training Hours

List in-person training where the teacher and student are physically present in the same location.
Provide start date, end date, course or form studied, instructor or school, and total training hours.
Total Formal Qigong Training Hours: Add the hours listed above and enter the total.
Note: Up to 100% of your required 500 hours of Qigong training can be in-person for Level III.
Virtual Qigong Training Hours

List virtual training where the teacher and student are connected online and can see and speak to each other in real time.
Provide start date, end date, course or form studied, instructor or school, and total training hours.
Total Virtual Qigong Training Hours: Add the hours listed above and enter the total.
Note: Up to 25% of your required 500 hours of Qigong training can be virtual for Level III.
Related Studies Hours

List relevant studies in healing arts or personal practices that are meridian or acupoint based. These relevant studies need to incorporate some of the basic principles of Qigong such as Yin/Yang, the three Dan Tians, Jing, Qi and Shen, meridian/point knowledge and the Five Phases. This may include martial and religious Qigong training.
Provide start date, end date, course or form studied, instructor or school, and total training hours.
Related Studies Hours: Add the hours listed above and enter the total.
Note: Up to 25% of your required 500 hours of Qigong training can be related studies for Level III.
Please provide supporting documents for training hours. Examples include certificates of completion, training schedule, and letters of reference.

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Questions

Please answer the following questions to help the Certification Committee better understand your training background, teaching experience, and approach to Qigong.
YesNo
2. If yes, of whom? If no, what are the names of your primary teachers?
NOTE: A student of an NQA Certified Senior Teacher may, in lieu of presenting documentation from that teacher, submit a strong letter of recommendation from the NQA Certified Senior Teacher that includes the number of hours of relevant instruction, a general description of coursework, and comments about the student’s ability. Hours of experience must still be listed on this application. If your primary Qigong teacher or other important teachers who helped shape your practice are deceased or cannot be reached, please include a reference letter from someone within the school or lineage, or from a fellow student who trained with you at the time.
3. What type/style of Qigong do you use in your clinical practice and why?
4. When did you start the practice of Qigong healing? (month/year)
5. When did you start performing treatments on clients outside of a class setting? (month/year) This would be time spent independently as a clinician in cultivation of healing others primarily through Qigong application.
6. What is the current schedule of your Qigong healing practice? Please list the average number of patients you see per week and average time spent with each patient.
7. Tell us more about your Qigong clinical practice experience.
8. When did you begin writing articles, books, or published papers about Qigong?(Please skip this question if it doesn’t apply to you)
9. In your own words, how would you describe Qigong?
10. How would you explain the basic principles of Jing, Qi, and Shen?
11. What is the role of mind/intention in Qigong practice?
12. How would you begin and end your clinical practice to be most effective?
13. Have you ever been convicted of a crime? If “yes”, please explain briefly
14. Have you ever been denied a professional license/certification or had one revoked? If “yes”, please explain briefly.
Letters of References

Please arrange for three (3) letters of reference to be sent directly from your references to the NQA Certification Chair at certification.chair@nqa.org.

A. Reference Letter from a Primary Qigong Teacher

This letter should describe the Qigong training for which you reported training hours in this application.

This reference should include:
- A brief description of the reference’s background as it relates to your Qigong studies
- How long the reference has known you
- How long you studied with this reference
- The subjects studied and the duration or frequency of your training
B. Professional Reference from a Supervisor, Peer, Student or Client

This reference should include:
- How the reference knows you
- How long the reference has known you
C. Reference to Personal Character

This reference should include:
- How the reference knows you
- How long the reference has known you
Please list the individuals from whom the committee should expect to receive letters of reference:
Primary Qigong Teacher Reference
Professional Reference
Personal Reference
Attestation

I attest that all information submitted in this application is truthful and accurate to the best of my knowledge. I understand that incomplete or intentionally misleading information may result in the denial of certification. Please sign and date below.
Signature

Clear
Date

MonthDayYear
Date

Application Fee*

Application Fee

The application fee helps support the time and administrative work required for the Certification Committee to review and evaluate each submission.

$100.00 Quantity

Total

$0.00

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Qigong Senior Clinical Practitioner Application Form

Contact Info

Qualifications

*Formal Clinical Qigong Training (FCQT)

Formal Clinical Qigong Training Hours

Virtual Qigong Training Hours

Related Studies Hours

Questions

Attestation