Application for Qualified Mentorship Status

Please fill out the application and attach all related materials. Keep a copy for your records. Allow six weeks for processing and response from the HTP office

Submission date:

Last Name: First Name:

Address:

City: State/Province:

Zip/Postal Code: Country:

Applicable Credentials:

Include the phone number(s) and e-mail address to be used by HTP for communications and the website Practitioner/QM listing:

Home Phone:

E-mail:

Cell Phone: Work Phone:

Check the boxes that apply for your Practitioner/QM website listing:

I charge for mentoring	I don’t charge for mentoring

I mentor individuals	I mentor groups

I will mentor long distance	I only mentor (location)

I am accepting new mentees	I am not currently accepting mentees

I am willing to supervise other’s mentorships

For purposes of the HTP data base please share:

Your professional credentials:

Job Titles that you hold or have held that you consider significant in your role as a practitioner or mentor:

© Copyright 2010 Healing Touch Program	HTP-942-A Rev 05.30.11

Margaret Nies

2011-05-31