Practitioner Name *

First Name

Last Name

Practitioner Type

Please select your provider type from the list below (Select all that apply)

Doctor of Chiropractic (DC)

Doctor of Optometry (OD)

Doctor of Osteopathy (DO)

Licensed Acupuncturist (LAc)

Medical Doctor (MD)

Naturopathic Physician (NMD/ND)

Nurse Practitioner (NP)

Occupational Therapist (OT)

Physical Therapist (PT)

Registered Nurse (RN)

Speech Language Pathologist (SLP)

Other

Other post-graduate training completed?

Please select all that apply.

FIBFN - FN (Fellowship, IBFN - Functional Neurology)

FIBFN - CND (Fellowship, IBFN - Childhood Neurodevelopmental Disorders)

Foundations Certificate - Track 1

Concussion Certificate - Track 2

DACNB (Diplomat American Chiropractic Neurology Board)

FACFN (Fellow of the American College of Functional Neurology)

Melillo Method TM Certification

Other