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Integrative Medicine
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Consultation Service Information Request Form

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Information Request Form

What kind of organization do you represent? *

If 'Other' please elaborate

Describe briefly the type(s) of patients you see

How many patients do you see annually?

How many staff are employed at your organization?

Is your organization... *

profit
not-for-profit?

Describe briefly what your role is in your organization

Describe briefly where you are in the process of implementing an Integrative Medicine Program

Describe briefly what level of support you have

Have you read our Building Bridges online book? *

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What modalities do you have and/or are interested in discussing?

Acupuncture
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Reflexology
Music Therapy
Art for Healing
Homeopathy
Massage Therapy
Qigong
Guided Imagery
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Integrative Medicine

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