Partnership Inquiry Form

Let’s explore how we can support patients together.

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Full Name *

Professional Title *

e.g., MD, LCSW, RN, NP, PT, Patient Advocate, etc.

Organization/Practice Name

Email Address *

Phone Number

How would you describe your current role or work? *

What best describes your interest in reaching out? (Choose all that apply) *

• Referring a patient or client to coaching
• Learning more about coaching for chronic illness
• Third Exploring a professional collaboration or partnershipChoice
• Inviting me to speak or present at an event
• Accessing resources for patients or families
• Other (please describe below)

your illness

Do you serve clients/patients living with chronic illness? *

• Yes
• No

If yes, what types of chronic illness or challenges do you most commonly encounter in your work?

How would you prefer I follow up with you? *

• Email
• Phone call (please be sure to provide phone number above)

Is there anything else you'd like to share?

Submit