LoveStrong Team Member Info Please enable JavaScript in your browser to complete this form.Personal Info:Name *FirstLastCredentials to be listed after your name:Date of Birth (Month and Day Only): *Phone *Email *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmergency Contact Name *Emergency Contact Relationship *Emergency Contact Phone *Preferred Method of Communication for COLLEAGUES: *TextEmailPhoneWhich contact info would you prefer COLLEAGUES use to contact you" *Personal contact info.Business contact infoCheck this box if I we may include your info on our colleague directory (Highly Recommended - Accessible by LoveStrong Affiliates ONLY)Business Info:Business Name *Business Contact Info (email, phone, website) *Social Media Used for BusinessInstagramFacebookTik TokTwitterYouTubePinterestSocial Media HandlesPreferred Method for CLIENTS to Contact You (List in order from first to last choice: online booking, email, text, phone). *Do you have other contact preferences? *Expected Days/Hours of Operation *Do you accept insurance? *YesNoMaybeList insurance plans you accept:Do you provide superbills? *YesNoMaybeUpload your headshot (use highest quality file possible): Drag & Drop Files, Choose Files to Upload Upload your logo (use highest quality file possible): Drag & Drop Files, Choose Files to Upload Provide your hex code colors for the primary colors for your business:Let me know if you need help with this one. If you use Canva, they are easy to find on your color palate.List your bullet points that you'd like included on the Provider Wall in the office:Email for an example if needed. Fun Info:Hobbies, family, etc.:What are some of your favorite things (food, restaurants, stores, etc.)?Anything else you'd like to share:Submit
