Affiliation Interest FormPlease 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 Physical TherapyAcupunctureChiropracticDoula ServicesMassageNaturopathicOccupational 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/FathersLGBTQ+Infants/ChildrenCaregiversFamiliesProvidersAs an affiliate, are you interested in office space, classroom space, or collaboration only (check all that apply)?Office SpaceClassroom SpaceI offer Classes ONLYCollaboration Only (Preferred Community Partners)Please provide any additional information that will be helpful in us determining your eligibility for affiliation. Checkboxes *I have read and understand the Affiliation Criteria and would like to be considered for collaboration.Affiliation Criteria – In Office at LoveStrong (or mobile) - Services include the preconception, prenatal, postpartum, or pediatric populations. - Provides services including, but not limited to, lactation, chiropractic, pelvic floor therapy, acupuncture, doula, naturopathic, massage, occupational therapy, mental health, nutrition, fitness, pediatrics, wellness, or other with Clinic Director approval. - Received education for preconception, prenatal, postpartum, or pediatric population specialty from a school that is accredited by a nationally recognized accrediting organization. - Has state licensure or formal certification for prenatal, postpartum, or pediatric population specialty provided. - Has received approval by at least two affiliates of LoveStrong, including Clinic Director. - Provides holistic and evidence-based services and/or education. - Is working in office at LoveStrong Wellness or provides mobile services only. Affiliation Criteria - Classes Only - Services include the preconception, prenatal, postpartum, or pediatric populations. - Provides services including, but not limited to, lactation, chiropractic, pelvic floor therapy, acupuncture, doula, naturopathic, massage, occupational therapy, mental health, nutrition, fitness, pediatrics, wellness or other with Clinic Director approval. - Received education for preconception, prenatal, postpartum, or pediatric population specialty from a school that is accredited by a nationally recognized accrediting organization. - Has state licensure or formal certification for prenatal, postpartum, or pediatric population specialty provided. - Has received approval by at least two affiliates of LoveStrong, including Clinic Director. - Provides holistic, evidence-based, educational, or community type classes. - Provides education or recreational class for moms, babies, fathers, caregivers, or families. Preferred Community Partners - LoveStrong Extended Referral Network - Serviced include the preconception, prenatal, postpartum, or pediatric populations. - Provides services including, but not limited to, lactation, chiropractic, pelvic floor therapy, acupuncture, doula, naturopathic, massage, occupational therapy, mental health, nutrition, fitness, pediatrics, wellness, or other with Clinic Director approval. - Received education for preconception, prenatal, postpartum, or pediatric population specialty from a school that is accredited by a nationally recognized accrediting organization. - Has state licensure or formal certification for prenatal, postpartum, or pediatric population specialty provided. - Has received approval by at least two affiliates of LoveStrong, including Clinic Director. - Provides holistic and evidence-based services and/or education. - Maintains a collaborative relationship and communication with LoveStrong Wellness - Is vetted and approved by provider in the same specialty, clinic director, and one other LoveStrong in office. Submit
