Provider Contracts & Forms

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Company name

Position

Address

City, State

Website or Social Media

What is your primary modality? (Reiki, Cupping, Sound Therapy, Herbalism, etc.)

List any secondary modalities or complementary services.

Are you certified or licensed in your modality? If yes, list credentials

Do you carry professional liability insurance?

Yes

No

Describe your approach to holistic and emotional wellness.

Do you offer in-person services, virtual services, or both?

In person

Virtual

Both

Are you willing to collaborate with other Providers?

Yes

No

Maybe

Why do you want to join The Elocin Network™?

Are you trauma-informed or open to trauma-informed training?

Yes

No

Optional

How familiar are you with culturally aligned or spiritually based healing? If so, what does it mean to you?

Are you comfortable working with our non-profit programs for vulnerable or underserved communities?

Yes

No

What is your general weekly availability?

Do you have a clean, professional space suitable for in-person sessions?

How many clients per week can you realistically take?

Are you comfortable conducting telehealth sessions?

Do you have reliable internet and private space for virtual sessions?

Are you willing to adhere to our code of ethics and confidentiality requirements?

Yes

No

Are you willing to complete a background check if working with youth or non-profit programs?

Yes

No

Are you interested in volunteering or offering low-cost services for underserved communities?

Yes

No

Upload Certifications, Proof of Insurance etc.

Below are the Forms& Contracts needed to start services.

Please fill out Interest Form so that we can learn more about you and ensure proper members are aligned with your services. Contract below is for viewing purposes only.

After form submission an email will be sent for signatures and welcome package.

Provider Contracts & Forms

Below are the Forms& Contracts needed to start services.

Please fill out Interest Form so that we can learn more about you and ensure proper members are aligned with your services. Contract below is for viewing purposes only. ​ After form submission an email will be sent for signatures and welcome package.

Please fill out Interest Form so that we can learn more about you and ensure proper members are aligned with your services. Contract below is for viewing purposes only.

After form submission an email will be sent for signatures and welcome package.