Self Care 1 on 1 Provider Application Form

Please fill out the form below. Wait to click the ‘Submit Application’ button at the bottom of the page until the form is complete and you are ready to submit it. You will not be able to ‘save’ the form for completion at another time. You can cut and paste your resume or other information from a word document directly into the form.

Please compose your answers to the following questions in a text editing program like Word, and copy and paste them from Word into the appropriate answer boxes. Sometimes form input gets lost so composing and saving your answers in a text document could save you a lot of reentry time if the form input is lost.

Your name:		Date:
Your occupation: How long have you been in this position? Your business name: Type of business: Your business address: Your business phone number: Other work phone numbers: Your fax number: Your e-mail address: Your alternate e-mail address: Your home address: Your home phone or cell phone: Do you prefer to receive HeartMath materials at your office or home? Who is your primary HeartMath contact? What HeartMath products or services have you used? Include all HeartMath workshops or seminars you have attended and when. What professional training have you received? Please include degrees, certifications and licenses held and dates completed. What professional organizations do you belong to? What is your professional experience working with individual clients in a 1 on 1 format? Please include dates. (e.g. I'm a wellness counselor and have been working with individual clients for 10 years. Currently I have about 10 clients a week and we meet face to face.) Why do you want to become a 1:1 Provider? How many people do you plan to teach HeartMath to within the next 12 months? Describe your targeted market and your relationship to that market. Briefly describe how you plan to market your HeartMath business. Give a brief résumé-type history of relevant profession, education and employment information in addition to that mentioned above. Please list contact information for 3 references.
Professional Name: Phone: Organization and title: Name: Phone: Organization and title:		Personal Name: Phone: Organization and title:
When you complete your 1:1 Provider training you will receive a certificate of completion. How would you like your name to appear on that certificate? e.g. Jane Smith, Ph.D. Kim Allen Director, Training and Licensing Programs HeartMath LLC 14700 West Park Ave. Boulder Creek, CA 95006 1:1 provider license does not allow for training groups or conducting any type of workshop or seminar. 1:1 provider license is only available to residents of North America and Australia. Submission of this application indicates that you have agreed to the following: I understand the submission of this application form alone does not guarantee acceptance into the 1:1 Provider Program. I agree that upon completion of my training as 1:1 Provider I will follow the terms and conditions stated in the 1:1 Agreement.

Sample License Agreement
1:1 FAQs
Application Form

Stephanie Herzog
Assistant Director, 1-on-1 Provider Licensing Program
Telephone: (800) 450-9111, Ext. 726 (Toll-Free)
Telephone: (831) 338-8700, Ext. 726 (International)
E-Mail: herzog@heartmath.com

1:1 Provider Application Form