Mirashift Therapist, Practitioner, & Administrative  Application
Thank for your interest in becoming a part of the Mirashift Team! Kindly respond to the prompts below, and expect follow-up from us by email or phone.

For those applying for administrative roles, please overlook the section on health credentials and provide your administrative qualifications instead, or simply denote N/A if the question does not apply.

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Email *
Phone Number *
First Name & Last Name *
Date of Birth *
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Mailing Address *
List your social media platforms (IG, FB, Twitter, LinkedIn, etc.) and corresponding handles.

Examples:
Instagram: @Mirashift
Facebook: facebook.com/Mirashift
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Please list the disciplines, including CPR, in which you are licensed, certified, or accredited to perform services as a therapist or practitioner for Mirashift. 

Examples: CranioSacral Therapy, Lymphatic Drainage Therapy, Positive Psychology, Sound Vibration Therapy, Hypnotherapy, Massage Therapy, EFT, etc.
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How did you hear about Mirashift?


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Are you in private practice or do you work within a group practice? Please indicate the website for your practice. 

If you are not currently practicing, please explain why.
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How many years have you been practicing your discipline(s)?*
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Do you have experience working with Pediatrics? Does your current practice include pediatric services?
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Please list any professional or relevant organizations that you are involved with. Tell us about your involvement. 
I agree to a background check being conducted. *
Tell us why you feel you are a good fit for Mirashift. *
How many hours are you available to work during the week? 
Which days of the week are you available to work? (check all that apply)
Have you ever had a malpractice claim or suit brought against you?  Y/N If so, please provide description and outcome of such claim or suit.

Your personal data information will not be shared with any non affiliated parties outside of Mirashift Therapy, PLLC and will be maintained based on our Privacy Policy. This information may be permanently stored in your personal data.
Is there anything else that you would like for us to know about you?
Required Documents

Please email the below required documents to Support@Mirashift.com

- Current Liability Insurance
- Current licensure in your state of practice
- Any other relevant credentials, licenses, etc.

An application is not considered complete until we have received all required documents. 
Please list at least 2 names and contact information (cell phone and/or email address) of professional references who are familiar with you and your work.  *
A copy of your responses will be emailed to the address you provided.
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