Be Well Practitioner List
Hello,

Thank you for your interest in joining our wellness provider list. Our mission is centered on increasing equitable access to preventative wellness services within our communities. Your contribution would be impactful.

We'd like to get to know you. Please take a few minutes to complete this form, we appreciate your time.



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www.bewellcommunitycollective.com
Name *
Email *
Phone number
Legal Business Name, if applicable. (NA if you are a sole proprietor.) *
Website URL (N/A or list another web link) *
Do you have current malpractice insurance? *
Do you have appropriate and current licensure and or certification to practice? *
List all current licenses. One item per line, please. (NA if none.) *
List all current certifications. One item per line, please. (NA if none.) *
In your opinion, do you feel you have received training and are competent in equity, inclusion, diversity and cultural awareness? *
What services can you provide? Please only list those you can offer at a neighborhood clinic, not all that you may offer at your personal practice site. *
Required
To build trust and consistency with our clients, we prioritize those practitioners who can commit to clinical service for a minimum of 6 months. Is this something you can do? *
Please give us an initial sense of your time availability. How many hours per week, or per month do you think you have to show up and serve as a Be Well clinic practitioner? If you know days of the weeks, and times, please include. *
Be Well believes it's important to compensate its clinic practitioners. Where possible, we provide a modest sum, which will likely be less than your usual fee. All of that said, we are not yet in a position to offer this to all new practitioners, nor to existing practitioners consistently. Please comment on your willingness, ability and/or constraints for providing pro bono treatments. *
What areas of Madison/Dane County are you able to engage in a clinic? *
Required
May we have your permission to list you on our website? (Note: This will only happen during your active engagement as a clinic practitioner.) *
Thank you, we will reach out to you should an we have an opening. Please feel free to share any comments below.
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