Network Application

EnGen Wellness Network Application

We’re excited that you’ve decided to apply to EnGen's Wellness Network as a wellness provider. Please complete the application and accept the Wellness Network Expectations. We’ll be in touch with next steps as soon as possible.

01. Primary Contact

First name

Last Name

Phone Number

Email Address

Mailing Address

Professional Title

Years of Experience

Education and Training History

The form has a 2000-character limit for your response

Licensing and Credentials:

The form has a 2000-character limit for your response

02. Wellness Organization Details

Practice Legal Name

DBA Name (optional)

Type of Medicine/Modalities Practiced

Please share with us any of your healing modalities.

The form has a 200-character limit for your response

Type of Services Offered

List your services and include pricing if possible.

The form has a 2000-character limit for your response

Practice Location(s)

List city, county, and or state. Include if available virtually.

The form has a 2000-character limit for your response

Availability

Provide an idea of your future availability.

The form has a 2000-character limit for your response

Ideal Client Demographics

Provide a description of the type of individuals you serve.

The form has a 2000-character limit for your response

Insurance Information

Provide a description of any insurance you contract with.

The form has a 2000-character limit for your response

Previous Experience with Network or Collaborative Work

The form has a 2000-character limit for your response

03. Professional Philosophy

What are your current organizational goals?

The form has a 2000-character limit for your response

How do you believe your business aligns with EnGen values?

The form has a 2000-character limit for your response

What motivates you to continue in the wellness industry?

The form has a 2000-character limit for your response

04. Terms and Conditions

Consent to Background Check

Yes, I agree that EnGen can conduct a background check. This includes contacting clients you've provided testimonials for as well as using a professional background check company. I agree to provide any additional information needed to conduct that.

Agreement to Network Expectations

I have read the EnGen Network Expectations and agree to abide by the expectations as stated within. I also understand that these expectations can be revised at anytime and by agreeing to these expectations now, I agree to follow any revisions unless another agreement is made at that time.

Thank you! Your submission has been received!

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EnGen Wellness Network Application

Get Early Access to EnGen