LYB Yoga Program Clinical Connector: Application
Thank you for your interest in joining our network of Clinical Connectors to help us raise awareness about the LYB Yoga Program through clinical avenues. We believe that working alongside clinicians will help make yoga and meditation more accessible to the TBI community, and as a result, offer an important opportunity for augmenting the healing process.
Please share the following information:
Name: *
Your answer
DOB: *
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City: *
Your answer
State: *
Your answer
What is your email address? *
Your answer
Please complete the following details with the information you would like us to list on our website:
Degree(s): *
Your answer
TBI/medical specialty (if relevant): *
Your answer
Clinical institution affiliation: *
Your answer
What is your Clinical Facility's website? *
Your answer
Do you have a TBI outpatient program? *
If yes, on average, how many outpatients does your facility serve per month?
Your answer
We'd love to hear your ideas for which organizations, rehab facilities, community groups, support groups, etc. that we should reach out to to share information about our program. Please list any ideas you have! *
Your answer
We'd love to hear your ideas for which local and national conferences you think LoveYourBrain should have a presence at, either as a presenter or as an exhibitor. Please list your ideas here! *
Your answer
Will you be presenting at or attending any conferences in the near future? If so, would it be appropriate to share information about LoveYourBrain? (We will gladly supply materials, talking points, etc.) *
Your answer
How can we reach you at your clinical facility?
Address: *
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City: *
Your answer
State: *
Your answer
Zip: *
Your answer
What is your phone number at work? *
Your answer
Short quote about why you support the LYB Yoga program: *
Your answer
As a Clinical Connector, you are agreeing to voluntarily help refer your patients to your local LYB Yoga Program. Specifically, please indicate by checking the boxes below that you agree to try your best to accomplish the following:
*
Required
In exchange, LYB will:
● Provide all program materials for free (or access to the materials on our website).
● Feature you on our website to raise awareness about your voluntary role in LYB and support of our program.
● Work with you to adapt materials for your context (where possible).
● Extend a sliding scale scholarship (we suggest $346, which is a 15% discount) to attend the LYB yoga teacher training workshop.
● Conduct an in-service training at your affiliated clinical institution (where possible).
● Organize a screening of the Crash Reel for your staff (where possible).
I have carefully read all of the above and fully understand the terms of this agreement.
Please type your full name. *
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