Name:
____________________________________________________________________
(Print
exactly as you want on your membership certificate; include your degree if
desired)
Clinic:
____________________________________________________________________
Address:
__________________________________________________________________
City:
____________________________________ State: _____ Zip: ________________
Type of
practice: ___________________________________________________ ¨ Retired
Phone:
_____________________________ Fax: ________________________________
E-mail
Address: ____________________________ Website: _______________________
I give
permission to send IFNH related material to my E-mail
¨ Please don’t use my E-mail
What schools did you attend?
____________________________________________________
Type & date
of Degree(s): ____________________ How long have you been in practice?
______
How
long have you been using nutrition in your practice?
¨
N/A ___________
How
many years experience do you have working in nutrition?
¨
N/A ________
Do you
use natural remedies?
¨ N/A ________ Do you use
Homeopathy? ¨
N/A _________
Have you
used any of the following clinical tools in your practice?
|
Symptom
Survey Software
The
Nutritional Exam
Acoustic
Cardiograph
Heart Rate
Variability
Bio Meridian
Testing
Page
Measurements |
Specter
Vision
Blood
Analysis
In Office Lab
(urine, blood, etc)
Hair Analysis
Saliva
Testing
Digestive
Assessments |
List any
other clinical tools:
_______________________________________________________
On a scale
of 1-10, how comfortable are you using the Nutritional Exam?
__________________
Have you
taken the Foundations of Nutritional Therapy Course (FNT)? ____ If yes,
when?_____
Have you
taken any other courses from any of the following people in the last 2
years?
|
Jeremy E.
Kaslow, MD, FACP
Michael
Dobbins, DC
Jay R.
Robbins, DC
Stuart White,
DC
Ernest
Caldwell, DC
|
Bruce Bond,
DC
Ray Bisesi, DC
Fred Ulan, DC
Janet Lang, DC
Holly Carling
OMD Lac
|
Please document
any classes taken from the above list separately
Circle the type
of energy work you use in your practice: None–CRA–NET–AK–ART – NRT – other
Circle any
certification in nutrition you have already obtained: DACBN – CCN – CNC – NTT
Do you have any
certifications that you use in your practice that were not listed?
________________
When did you get
certified? _______ How many hours were required for certification? ___________
How many staff
members are in your practice? _______ How many are used clinically? __________
What are their
credentials? ________________________________________________________
How many staff
members are involved in your clinical nutrition practice? ______________________
Would your staff
be interested in becoming a Certified Whole Food Nutrition Technician? _________
List the types
of patient education programs you use _____________________________________
What points do
you emphasize? ____________________________________________________
What information
would you find most supportive for a patient education program? _____________
For additional educational programs:
Circle the time structure(s) you would prefer:
(All Day - Saturday - Saturday &
Sunday - 1 ½ hour - 2 ½ hour - Thursday - distant learning program)
For our distant learning program the
lecture will be conducted via phone conference. You will receive the PowerPoint
and Notes for the lecture on a CD for use in your home or office computer while
you are listening to lecture.
Requirements and Cost
The cost of the 100-hour CCWFN Certification Program runs between $1250 to $1750
depending on the recommended reading materials and the number of outside credit
hours completed. Professional or Technician Membership is included in the
above price structure. As an example applicants can reduce the overall
cost by receiving credit for up to a maximum of 30 hours of outside instruction
from seminars given by the instructors listed on the application and reviewed by
IFNH. The certification program is based on
the Nutritional Exam and
the Foundations of Nutritional Therapies program. , which encompass certain basic
philosophies and procedures, making the FNT course a requirement. For those
who have taken the FNT program over the past 15 years, a review program is
available at a reduced fee.
Please
review my certification and professional membership application
name___________________________________________
Date________________
$25.00
Application Fee
¨
Check
¨Visa
¨ MasterCard #__________________________________________ EXP: _____________
3-Digit
Code: _____________
***
Upon review of the necessary courses and costs, there are two payment plans
available.
·
One Payment based on
review of application and determination of remaining required courses.
·
Monthly Payment Plan
$600 initial payment and 12 equal payments of the remainder (A $4 processing fee for each monthly
payment will be included)
IFNH reserves the right to
refuse membership to those who do not meet the criteria of the review board.
FAX:
(858)-488-2566 or MAIL: IFNH 3963 Mission Blvd. San Diego, CA 92109
|
