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Integrative Medicine
Consultation Service Information Request Form

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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? *

Yes
No

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

Acupuncture
Reiki Therapy
Reflexology
Music Therapy
Art for Healing
Homeopathy
Massage Therapy
Qigong
Guided Imagery
Tai Chi
Stress Management
Therapeutic Touch
Others (describe below)

What other issues would you like to discuss when we contact you?

Your Information

Name *

Organization *

Address

Street

Apt/Bldg

City *

State/Province

Postal Code

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Phone Number *

Email Address *

Security Code *

Integrative Medicine

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