2022 Application for the Healer's Art FDW Training

1. Name and Education History *This question is required.

First Name
Last Name
Advanced Degree
School
Year of Graduation
License #
State of Issue

2. What type of program are you interested in bringing The Healer's Art curriculum to? *This question is required.

Medical School where you will teach The Healer's Art *This question is required.

School Name
Address
City
State, Zip
Country

Institution where you will teach The Healer's Art *This question is required.

Institution Name
Address
City
State, Zip
Country

If "Other," please explain.

What is your planned role in The Healer's Art course? *This question is required.

What is your planned role in The Healer's Art for Residency? *This question is required.

What is your planned role in The Healer's Art program? *This question is required.

If "Other," please explain.

3. Professional Specialty *This question is required.

Professional Position *This question is required.

University or School
Academic Title
Professional Role
Years in Position

Professional Position *This question is required.

Institution
Title
Professional Role
Years in Position

Professional Position (if more than one held concurrently)

University or School
Academic Title
Professional Role
Years in Position

Professional Position (if more than one held concurrently)

Institution
Title
Professional Role
Years in Position

4. Work Contact Information *This question is required.

Name
Address
City, State, Zip
Country
Work Phone
Work Fax
Work Email

5. Home Contact Information

Address
City, State, Zip
Country
Home Phone
Cell Phone
Home Email

7. How did you hear about The Healer's Art? *This question is required.

What courses do you teach at your Medical School? *This question is required.

Have you taught or directed similar programs at your institution? If so, please describe. *This question is required.

8. When do you plan to implement The Healer's Art curriculum?

Start Date

9. What institutional support do you have for this plan?

10. What do you anticipate is the greatest obstacle you may encounter in implementing this program?

Approximately how many students are in each class at your Medical School? *This question is required.

Approximately how many participants do you expect to serve at your institution? *This question is required.

How do you think that The Healer's Art will serve your medical students, i.e. what are their unmet needs? *This question is required.

How do you think that The Healer's Art will serve your colleagues, i.e. what are their unmet needs? *This question is required.

11. What draws you personally to teaching this course? Please describe briefly. *This question is required.

12. Do you have any experience leading small groups or workshops? *This question is required.

13. Please tell us one way that being a physician has enriched your life. *This question is required.

14. Do you have any health care needs that our staff should know about? Please describe.

15. Is there anything else you would like us to know?

CME credit for this workshop training will be forthcoming.

CANCELLATION & REFUND POLICY: A deposit of $300 is due at time that your application is accepted. The balance is due by June 15, 2022. A full refund of deposit (less processing fee of $25) will be issued for cancellations on or BEFORE July 1. Cancellations after July 1 will forfeit deposit.

2022 Application for the Healer's Art FDW Training

2022 Application for the Healer’s Art Faculty Development Training