Membership Application Form

  1. ID information: Please list your name, professional designation (MD, PT, etc.), name of practice (if a d/b/a that is other than your own name), primary business address, and business phone/fax/e-mail/website (whichever are applicable).  Also list your residential address and best telephone contact (home, cell, or office).
  2. License information: Ohio professional license number and expiration date.
  3. Educational background: Please list your undergraduate, graduate, and, if applicable, post-graduate and post-doctoral education.  Provide name of each school, years attended, graduation dates of completed programs, and degrees earned.  Advanced or specialty trainings with certifications (including board certifications) may be included.
  4. Professional experience: How many years have you been in practice?  Do you have any areas of specialization within your field?  What problems and types of patients does your practice tend to focus on?  Please attach a resume, curriculum vitae, or simple summary of your work experience that includes venues, dates (years), title (if other than practitioner/sole proprietor), and principal responsibilities at each location.
  5. Continuing education: How many CEU’s/PDA points are required to maintain your license?   Attach a list of all continuing education courses (lectures, seminars, workshops, symposia) you have attended or given, as well as any other professional development activities you have engaged in that are recognized by your profession’s credentialing bodies, over the past five years.
  6. Please write a few paragraphs that describe your professional practice, including your personal approach to health care and the specific ways you structure and run your practice. How much time do you spend with each patient?  How do you work to uncover underlying causes of the problems your patients or clients present?  Include any information or perspective you feel would shed light on your health care philosophy and individual practice.
  7. What is it about your work that elicits your passion, and how do you believe the way you conduct your practice reflects that passion?
  8. In what ways do you demonstrate professional engagement outside the treatment room? (The broad range of professional outreach activities that can qualify as “outside engagement” is suggested in Point 9 of the Consortium admissions criteria.)
  9. Please provide us with three references: a colleague familiar with your practice and your character, a personal contact (other than a family member) who has known you well for more than three years, and a patient willing to speak about his or her experience with you as a practitioner.  (Any such communications will be kept in strict confidence and will not be used for any purpose other than considering an applicant’s suitability for membership.)
  10. Have you ever had your license revoked or suspended? If so, please explain the circumstances of the action and its ultimate resolution.
  11. Have you ever been convicted of a felony? If so, explain the circumstances and outcome of the situation.
  12. Has any form of substance abuse ever impaired your professional conduct or performance? If so, please detail the circumstances and indicate whether any such impairment continues to pose a problem.