Individual Practice Application

Wellness providers representing inpatient treatment facilities, training programs, or wellness products are encouraged to contact the FOP National Officer Wellness Committee at officerwellness@fop.net or at (615) 878-2620 for further information about becoming an FOP Vetted & Approved Wellness Provider. Individual practitioners wishing to become part of the network of FOP Vetted & Approved Wellness Providers are asked to complete the following information for use by the FOP National Officer Wellness Committee. Upon receipt and review by the Committee, you will be contacted to schedule an interview.

Name(Required)

Prefix First Last Suffix

Name of Practice(Required)

Physical Address of Practice(Required)

Street Address Address Line 2 City State ZIP Code

Office Phone(Required)

Cell Phone

Email(Required)

Website (if applicable)

Overview of clinical practice

Length of time in clinical practice(Required)

Type/modalities of therapies offered(Required)

Telehealth available?(Required)

Yes

Philosophy of Practice

Payment forms/insurance accepted(Required)

Licenses and Education

State(s)/License number(s)(Required)

List any special certifications received related to work with law enforcement or first responders

List any professional relationships or affiliation with law enforcement or first responder agencies or organizations

Please upload practitioner photo and logo, if available

Drop files here or

Accepted file types: gif, jpg, jpeg, pdf, png, tif, webp, Max file size: 1 MB, Max files: 2.

Photos should be a minimum 540 x 720 pixels and logos should be a minimum 960 pixels on the long side.

Comments

This field is for validation purposes and should be left unchanged.

Overview of clinical practice

Licenses and Education

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