Affiliation Interest ApplicationPlease answer the questions below if you’d like to be considered for affiliation with LoveStrong Wellness. LoveStrong has developed a mission statement that reflects our goals and vision to support prenatal and postpartum families. We have established criteria to determine services that reflect this vision, and your answers will help us consider eligibility.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *PhoneWebsite / URLDo your services include the preconception, prenatal, postpartum or pediatric populations (check all the apply)? *PreconceptionPrenatalPostpartumPediatricsWhich services do you provide? *LactationPhysical TherapyPelvic Floor TherapyAcupunctureMassageNaturopathicOccupational TherapyMental HealthSpeech ServicesFitnessNutritionWellnessOtherIf you checked "Other", please explain your services here.Have you received specialized education and training in preconception, prenatal, postpartum, or pediatric populations from a nationally accredited organization?YesNoPlease list your education specific to your services here:Do you have state licensure or formal certification for the preconception, prenatal, postpartum, or pediatric population specialty services you provide?YesNoPlease list your licensure or formal certification credential here:Do you provide educational or recreational classes for mothers, fathers, infants/children, caregivers, families, or providers?YesNoWho do you provide educational or recreational classes for (check all that apply)?Women/MothersMen/FathersInfants/ChildrenCaregiversFamiliesProvidersAs an affiliate, are you interested in office space, classroom space, or collaboration only (check all that apply)?Office SpaceClassroom SpaceCollaboration OnlyPlease provide any additional information that will be helpful in us determining your eligibility for affiliation. Submit
