THE LUKE CHURCH WELLNESS FAIR - 2026
  • Mental Health Fair | Licensed Professional & Agency Application

  • THE LUKE CHURCH WELLNESS FAIR - 2026

  • Licensed Professional & Agency Vendor Application

  • CONFIDENTIAL — FOR REVIEW COMMITTEE USE ONLY

  • ELIGIBILITY NOTICE: Participation is exclusively open to individuals holding a current, active state-issued clinical mental health license or is a certified fitness and wellness instructors. Individuals holding non-governmental or non-clinical certifications do not meet eligibility requirements and will not be approved.

  • SECTION 1 — Organization & Contact Information

  • SECTION 2 — Licensure & Credentials REQUIRED FOR PARTICIPATION

  • All fields in this section are mandatory. Incomplete or vague responses will disqualify your application.
  • Page 1 | Part 1 of 3: Application Form
  • Mental Health Fair | Licensed Professional & Agency Application

  • Certifications from coaching programs, or non-governmental bodies do not constitute clinical licensure.

  • 4. List the professional license or certification type(s) held by all representatives attending the fair:

  • Rows

  • SECTION 3— Clinical and/or Wellness Services & Scope of Practice

  • 12. Do you offer telehealth services in addition to in-person care?

  • SECTION 4 — Health Fair Participation

  • 13. What materials, resources, or activities do you plan to offer at your booth?

  • 14. Will you conduct any on-site assessments, screenings, or consultations? If yes, confirm all will be administered by a currently licensed clinician:

  • 15. How many representatives will be present at your booth? Will all hold an active state clinical license/certification at the time of the event?

  • SECTION 5 — Attestation & Signature

  • By signing below, you attest that all information provided in this application is accurate and complete, that all representatives who will attend the Health Fair hold a valid, active state-issued clinical mental health license at the time of the event, and that you understand misrepresentation of credentials will result in immediate disqualification and removal from the event.
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