NEIWH Health Practitioner Listing

Application Form

 

 

 

Personal Information

 

First Name:  ­­­­­__________________   Last Name: ______________________

 

Email:  ____________________________   Phone Number: (      )________ __

 

Business Address: __________________________________________________

 

City: _____________         State: ___________________   Zip: ______________

 

Web Address: _____________________________________________________

 

Name of the Company / Business: _________________________ 

 

Are you an LMT?     □Yes    □ No    

 

Skills (You can select 10 most applicable skills)

 

□ Acupressure

□  Acupuncture

□ Alexander Technique

□  Animal Therapy

□ Applied Kinesiology

□ Aromatherapy

□ Ayurveda

□ Bioenergetics

□ Biofeedback

□ Breema

□ Chair Massage

□ Chiropractic

□ Colonic Therapy

□ Craniosacral

□ Doula Training

□ Energy Healing

□ Feldenkrais

□ Feng Shui

□ Flower Essences

□ Grigorain Method ®

 

□ Grigorian Organic Spa     Reflexology ®

□ Hakomi

□ Hellerwork

□ Herbal

□ Holistic Nursing

□ Holistic Skin Care

□ Homeopathy

□ Hydrotherapy

□ Hypnotherapy

□ Iridology

□ Jin Shin

□ Lomi Lomi

□ Massage Therapy

□ Macrobiotics

□ Midwifery

□ Naturopathy

□ Neuromuscular

□ Nutrition

□ Ohashiatsu

□ Ortho-Bionomy

□ Osteopathy

□ Polarity Therapy

□ Reflexology

□ Reiki

□ Rosen Method

□ Rubenfeld Synergy

□ SHEN Therapy

□ Shiatsu

□ Sound Healing

□ Spiritual Healing

□ Structural Integration

□ Tibetan Medicine

□ Trager

□ Tui Na

□Yoga

□ Zero Balancing

□ Other (Please Specify)

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Other Qualifications: __________________________________________________________

_____________________________________________________________________________

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How long would you like to have your profile be available on NEIWH.com?:__Month__Yr.

 

Select Package: 

 

□ Basic - $10.00/month, Advertise your business name, mailing address, telephone number, and e-mail address.

 

□ Deluxe - $12.00/month, Advertise your business information (listed above) and a link to your website.           

 

 

Select Payment Type: 

 

□ Check              Check Number:________

□ Money Order   Money Order Number: _____________

 

 

Total Amount Enclosed: $____________  

 

Please Mail application with payment:

NEIWH

Attn: Admissions

22 Bridge Street

Manchester NH 03101

 

Note: Profiles will be listed upon receipt of the payment. Incomplete forms may result in delay of listing. Please make your checks payable to N.E.I.W.H.

 

 

Signature:_________________________________Date:__________________

 

For Office use only:

Date Receieved:___________ Processed:_____________ Incomplete:____________

ProfileId:____________________