HeartMath^® Interventions Certification Program Application

Personal Information

Where would you like us to send your course materials? (Please no P.O. Boxes.)

Please list the professional license(s) or certification(s) you currently hold:

Our education partner, Collaborative Medical Education Institute, is providing continuing education credit for the professions listed below. Please indicate for which of the following professions you qualify and would like to receive CEUs/CEs:

If you are a student in an academic or professional track (Masters or PH.D. program internship), please describe the program and tell us the name and address of the institution along with the projected date of completion.

If your primary goal is to use HeartMath protocols in a research or dissertation study, please provide the name and address of the institution and type of research.

Where do you treat most of your clients or patients? Please include facility name and address.

How do you describe the majority of patients/clients you treat?

Private (fee for service)
Community-based agency (e.g. Outreach services)
Institutional (e.g. university health services)
Hospital or clinic
Other (please explain)

Reference Contact

Please list two professional references:

Reference Contact #1

Reference Contact #2

Upon completion of the program you will receive a certificate. Please indicate how you prefer your name to appear on your certificate. e.g. Janet Connor, Ph.D.

I have read the sample HeartMath Interventions Certification Agreement and understand the terms and conditions I will be required to follow upon completion of the program.