Peer to Practice: Clinical Herbal Mentorship Registration Form

Registration Form & Waiver

Thank you for your interest in the Peer to Practice program. To ensure a rich and rewarding experience—including meaningful group discussions—we require applicants to have a minimum of two years of part-time or one year of full-time study in a formal herbal, naturopathic, or other healthcare education program.

If you’re unsure whether this program is the right fit for you, please don’t hesitate to reach out to us at info@cabreraclinic.com.

To register

Please complete the registration form below
Pay your program fees by following the link on the next page

Peer to Practice: Clinical Herbal Mentorship Program with Chanchal Cabrera Registration Form & Waiver

Phone

This field is for validation purposes and should be left unchanged.

Part 1: Contact Info

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Emergency contact: Name and Phone Number(Required)

Part 2: Prior Clinical Experience/ Training

Experience Level(Required)

*Please note a minimum of two years of part-time or one year of full-time study in a formal herbal, naturopathic, or other healthcare education is required for acceptance into the program

Clinician (please specify type and # of years in practice)

Student (please state the name of the institution and number of hours completed)

Other (please explain)

Please specify clinician type and # of years in practice

Please state the name of the institution and number of hours completed

Please explain your experience

Have you observed or conducted patient intakes in a herbal medicine clinic?(Required)

Yes

Cancellation Policy:

To ensure a rich and personalized experience, we limit the program to a small group of students. As a result, we are unable to provide refunds if you cancel after your fees have been paid. Zoom recordings will be provided for any classes you are unable to attend. We do not provide make-up classes.

Submission of Case Reports and Questions

Successful applicants are invited to submit clinical questions or cases for review up to seven (7) days prior to each mentoring session. Please note that, due to time limitations, not all submissions may be discussed during the two-hour session.

I understand that submission of a question or case does not guarantee that it will be selected for review.(Required)

I Agree

Chanchal retains all intellectual property rights, including but not limited to copyrights, trademarks, teaching materials, lecture notes, recordings, handouts, designs, and any other creative output developed, provided, or presented in connection with the mentoring sessions.

I understand that I may not use, distribute, modify, or reproduce any of these materials for any purpose other than for my own personal use.(Required)

I Agree

I agree to maintain the confidentiality of Chanchal’s proprietary information, including but not limited to teaching methodologies, program content, and personal data, both during and after the program. Additionally, I agree to maintain the confidentiality of any and all private health information pertaining to patient cases discussed within the mentoring sessions.

I agree to maintain the confidentiality of Chanchal’s proprietary information.(Required)

I Agree

The information provided during these sessions, including discussions, materials, and other resources, is for educational purposes only and is not intended to qualify participants to practice medicine, prescribe treatment, or provide medical diagnosis. Students are reminded that completing this program does not grant them the legal authority to act as licensed healthcare practitioners unless they are otherwise qualified and licensed to do so. < /p>

I agree to indemnify and hold Chanchal Cabrera harmless from any and all claims, damages, losses, or expenses (including legal fees) arising from the improper use of the information provided through the mentoring program(Required)

I Agree