Join me and my team of top experts for a five-day immersion into the wisdom of wholistic healing to become a Wholistic Practitioner


Thank you for considering the program! Spaces are limited, and applications are reviewed and considered in the order they are received. Please enter all requested information in the spaces provided and you will be contacted after your application has been reviewed. We want to make sure you are fully aligned and ready to create a massive impact on the medical field.


Personal Information


Birth Date:

Where are you located?

Email Address:

Phone Number:


Eligibility and Background Information

You must have a background in/be currently practicing as a physician, nurse, or other healthcare practitioner to be eligible for this program. Please describe your eligibility by briefly listing your level of licensure and work experience below.

Would you be willing to travel outside the country to attend this program?


Have you ever had your certificate or license to practice in your healthcare field subject to limitation, discipline, revocation, or other sanction, including voluntary limitation, by a regulatory board or professional organization?


Is $10,000 a price you would be prepared to pay for this program?




How did you find out about the program?

Are you currently incorporating any holistic methods in your practice? If so, explain.

What is one of the most unique qualities about you that you’d like to share?

Is there any other information you would like to share as part of your application?


Agreement Information

I hereby apply for Wholistic Practitioner Certification Program. I understand that Certification depends upon my ability to meet all eligibility criteria. I understand that information supplied is subject to audit and that failure to respond to a request for further information may be sufficient cause for my application to be withdrawn from consideration. I further understand that the information acquired in the certification process may be used for statistical purposes and for the evaluation of the certification program. To the best of my knowledge, the information supplied in this Application is true, complete, and correct and is made in good faith.




Please attach a copy of your resume that details your skills, experience, and accomplishments and a current copy of your professional license in good standing.