Comfort Care Practitioner Application

PERSONAL INFORMATION

Full Name:

First Middle Last

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email:

Phone:

Start Date Availability:

Tier Preference(s)

Tier 1: Life-limiting diagnosis, chronic care treatment

Tier 2: Hospice eligible, limited life expectancy

Tier 3: Actively passing, days/weeks to live

PRACTICE INFORMATION

Practice Name:

Website:

Social media handles:

Organizational affiliations(s), if applicable:

EDUCATION

Highest level of education completed:

Name of school/university, if applicable:

Years attended:

Homeopathy Education:

Name of homeopathy school:

City/State:

Years attended:

Date of Graduation:

Homeopathy degrees/certifications/licenses held:

Additional Homeopathy Education:

CLINICAL EXPERIENCE

We are looking for practitioners with experience with this client population. Have you previously worked or had experience with severely ill or end of life clients? Please talk briefly here about your experiences and why you would like to part of this program.

Describe your experience:

Have you completed the HHN Comfort Care Practitioner Course? *Required(Required)

Yes

REFERENCES

Reference #1 Name:

First Last

Relationship:

Company:

Title:

Email:

Phone:

Reference #2 Name:

First Last

Relationship:

Company:

Email:

Reference #3 Name:

First Last

Relationship:

Company:

Email:

BACKGROUND CHECK CONSENT

A Background check is required for participation. You will be contacted by our vendor.

LIABILITY/MALPRACTICE INSURANCE

Company:

Policy information:

Dates and types of coverage:

Please upload a copy of your policy:

Max. file size: 50 MB.

DATA SUBMISSION AGREEMENT

HOHM Comfort Care Program will be collecting data and surveys on case outcomes and satisfaction for Research purposes. HOHM Foundation Comfort Care will make a positive difference for clients, families, friends and loved ones and within the field of End of life/Palliative Care. It will be important to monitor these results over time on behalf of Homeopathy and to continually improve the program. Practitioners must agree to submit MYCAW/other outcome measures and case information as part of your participation in this program.

Do you agree to submit the required data?(Required)

Yes, I agree to these requirements

No, I do not agree to these requirements

APPLICATION FEE

Coupon

Application Fee(Required)

Price:

Total

Credit Card

Cardholder Name

Card Details

SIGNATURE

I assert that the information presented on this application is accurate.

Signature

Date

Thank you immensely for your interest in this most important initiative to bring Homeopathy to the forefront of palliative and end of life care. Together we are breaking new ground in the name of Homeopathy and Comfort Care.

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PERSONAL INFORMATION

PRACTICE INFORMATION

EDUCATION

CLINICAL EXPERIENCE

REFERENCES

BACKGROUND CHECK CONSENT

LIABILITY/MALPRACTICE INSURANCE

DATA SUBMISSION AGREEMENT

APPLICATION FEE

SIGNATURE

HOHM FOUNDATION

homeopathy help network

HOHM RESEARCH