You need Flash Player 8 and Javascript enabled to view this content. Get Flash

HeartMath Interventions Certification Application

Before submitting your application, please review the HeartMath Interventions Certification
Agreement you will be required to sign upon acceptance into the program. Once we receive
your application, a HeartMath® representative will contact you to discuss program details and
answer your questions.

We recommend that you compose your answers to the questions in a word processing
program prior to completing the form and then copy and paste them into the form. Once you
click the 'Submit Application' button or close your browser you will not be able to access a
partially completed form so it's best to complete the entire process when you are ready to
submit the form.

Date:

Your name:

First:	Middle:	Last:	Suffix:

Title:

Employer:

Where would you like us to send your course materials? (Please no PO Boxes.)

Shipping Address

City:

State:

Zip:

Email:

Daytime Phone:

Cell Phone:

Please list the professional license(s) or certification (s) you currently hold:

Type:

Number and State:

Expiration Date:

Type:

Number and State:

Expiration Date:

Type:

Number and State:

Expiration Date:

Our education partner, Collaborative Medical Education Institute, is providing continuing education credit from the professional associations listed below. Please indicate for which of the following associations you qualify and would like to receive CEUs/CEs:

American Psychological Association

National Board for Certified Counselors

California Board of Behavioral Sciences (LCSW)

California Board of Behavioral Sciences (MFT)

National Association for Alcohol and Drug
Abuse Counselors

National Association of Social Workers

American Therapeutic Recreation Association

California Board of Registered Nursing

If you are a student in an academic or professional track (Masters or PH.D. program internship) please describe the program and tell us the name and address of the institution along with the projected date of completion.

If your primary goal is to use HeartMath protocols in a research or dissertation study please provide the name and address of the institution and type of research.

Where do you treat most of your clients or patients? Please include facility
name and address.

How do you describe the majority of patients/clients you treat?

Private (Fee for service)

Community-based agency (e.g. Outreach services)

Institutional (e.g. university health services)

Hospital or clinic

Other (please explain)

If you already have a HeartMath Contact, please tell us who that is:

What other HeartMath® program(s) have you taken? Please include city and dates.

What types of patients/clients do you typically see?

What client/patient outcomes do you hope to achieve with the addition of
HeartMath Interventions?

How many clients/patients per month do you estimate will receive HeartMath interventions?

Do you have an emWave® PC (or Mac Stress Relief System)?

Yes

Do you have an emWave Personal Stress Reliever®?

Yes

Which HMI series (start date) would you like to attend? Click here to view schedule

Describe your personal and/or professional experience with the HeartMath
tools and/or emWave technologies?

Please list two professional references:

Name:
Title:
Professional Relationship:
Email:
Phone:

Name:
Title:
Professional Relationship:
Email:
Phone:

Upon completion of the program you will receive a certificate. Please indicate how you prefer your name to appear on your certificate. e.g. Janet Connor, Ph.D.

Kim Allen
Director, Training and Licensing Programs
HeartMath LLC
14700 West Park Ave.
Boulder Creek, CA 95006

*I have read the sample HeartMath Interventions Certification Agreement and understand the terms and conditions I will be required to follow upon completion of the program.