STUDENT INTAKE FORM

name

phone number:

address

city

state

country

zip code

Tell us a little about your story, why you chose Rockwell as your holistic educator, and what brought you here? This doesn't have to be long, but it can be.

What holistic doctorate modality did you choose (indicate if not applicable).

the Doctorate of Traditional Naturopathy & Natural Medicine, TND/DNM®

the Doctorate of Clinical Global Herbalism & Botanical Medicine, CHD/MH®

the Doctorate of Advanced Holistic Nutrition & Nutritional Medicine, AHND®

the Doctorate of Spiritual Medicine & Root Causes, DSM®

the Doctorate of Functional Blood Chemistry & Functional Nutrition, DFBC/DFN®

the Rockwell Tri-Doctorate®

not applicable, I'm enrolling in the bioenergetic practitioner program

not applicable, I'm enrolling in a practice minor.

What's your birth date and age? (looks like 3/13/76)

Nutrition is the foundation of health, and Rockwell teaches traditional and modern diets across all cultures with non-bias to meet clients on every level for maximum inclusivity. Confirm your awareness of this practice and why we do it.

yes, I'm aware

When you complete certain holistic doctorates and practice minors at Rockwell, you can become board certified and ecclesiastically licensed:

understood

You can become a registered herbalist:

understood

Traditional naturopathy and licensed naturopathy are not the same. You'll be learning traditional naturopathy at Rockwell, after which you can become a holistically licensed, board-certified, traditional naturopath and doctor of natural medicine.

understood

Traditional naturopathic candidates who graduate from Rockwell call themselves Traditional Naturopathic Doctor, TND® and Doctor of Natural Medicine DNM®, depending on personal preference. Many graduates use both.

understood

Unless otherwise licensed to do so, holistic providers do not treat, diagnose, or prescribe. Instead, we target, reverse, and eliminate root causes with a focus on prevention.

understood

I understand that functional blood chemistry / testing is only available to US residents:

yes

Choose a 5-9 digit student ID number.

I agree to practice safely, ethically, and responsibly.

yes

I agree to always put people before profits.

yes

With our programs, you can receive ecclesiastical (holistic) board certification and licensing through third-party providers with decades of experience in protecting your right to access and practice natural, functional, holistic medicine.

yes

You acknowledge that our programs do not teach you how to practice conventional medicine, treat, diagnose, or prescibe? We do have physicians, physician assistants, autonomous nurse practitioners, and nurse practitioners, who can otherwise take these actions if operating under an active medical license.

yes, I acknowledge

If you had a call or spoke with someone at Rockwell, how would you rate your customer service experience?

good

great

excellent

not so good

could be better

not applicable, I didn't speak to anyone

I am who I say I am.

yes

Congratulations! Your Enrollment is Complete. Welcome to Rockwell.

Congratulations! Your Enrollment is Complete. Welcome to Rockwell.

The Rockwell Student Intake