Health Integration Center





	Expectations Technology Used Disciplines We Teach Opportunities

Application

Please give us your contact information:

Full Name:
Nickname:
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Please tell us about yourself:

Birthdate and Time:
Place of Birth:
Citizenship
Gender:	Male Female
Maritial Status:
Do you have any physical limitation?	Yes No If yes, please explain:
Do you have any addictions or habits that would impact working here?

Educational and Professional Background:
We accept all credentialed and qualified doctors (any kind), nurturers (nurses), consolers (counselors), bodyworkers and other therapists and wholistic practitioners.

Undergraduate Institution:
Date:
Degree Awarded/Field:
Graduate Institution:
Date:
Degree Awarded/Field:
Please list any additional Graduate work or degrees:
Post-Graduate Institution:
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Professional Work:

Current Practice:

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Private Practice?

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What are your specialties?

Have you published papers?

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If yes, please give details:

Tell us about your professional interests:

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Who is your most influential author(s)?

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Please share any other information you feel is important for us to know about you:

Which of the following interest you?

Preceptorship 2 -4 Year Student One Year Internship (In-House)

Please check all the disciplines you are interested in learning:

Nutritional Biochemistry	Herbology	Meridian (Zone) Studies
Light, Color, and Sound	Iridology	Flower (Bach) Essences
Live Blood Cell Analysis	Bolen's Test	Radiantouch (Bodyworks)
General Radiation Aging Sequence Pattern	Aromatherapy	Electrocardiography & Phonocardiography Testing
Luscher-Doodle Personality Testing	Float Tank Studies	Toxic Metal Hair Analysis
Urinalysis (chemical and microscopic)	Art of Interviewing	Researching the Internet (Wholistically)
Other topics:

Thank you for taking the time to fill this out. We will be in touch shortly.

Dr. Van Beveren