Therapist Application

Membership Application for Therapists

You can fill out this online form or download, print and mail a hard copy to:

Tina Steen
7 Hunting Ridge Drive
Simsbury, CT 06070
860-217-1062

This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Please by sure to enclose:

• CHT certificate

OR, IF COMPLETING FULL APPLICATION

• License (OT/PT)

• Registration (OT/PT)

If you have questions, please call 860-652-3370 or fax 860-650-3374.

Therapist Application

PART I: PERSONAL DATA

Name:

Title:

Address:

Business Address:

Home Phone:

Work Phone:

Fax:

Email Address: *

Are you a CHT
You automatically qualify for membership in the NEHS if you are a CHT (check here)

YES

If you are a CHT, please send a photocopy of your Hand Therapy Certification credential to Tina Steen, e: This e-mail address is being protected from spambots. You need JavaScript enabled to view it , f: 860-650-3374 , and skip to Part III.

PART II: PROFESSIONAL QUALIFICATIONS (Complete if not CHT)

1. PRACTICE REQUIREMENTS

Practice in Hand Therapy for a minimum of 2 years with at least 50% of caseload in upper extremity/hand rehabilitation (75% if part time). Non-direct services related to hand therapy, such as teaching or administration, will be considered.

Facility:

Dates of employment:

Hours per week:

Percent hand/upper extremity:

Percent non-direct:

Describe:

Facility:

Dates of employment:

Hours per week:

Percent hand/upper extremity

Percent hand/upper extremity:

Percent non-direct:

2. CREDENTIALS

Undergraduate institution:

Degree/date:

Graduate institution:

Registration number

QT PT

License number:

QT PT

State Licensed:

3. Continuing Education (past 2 years)

SEND A COPY OF YOUR CURRENT LICENSE AND REGISTRATION to Tina Steen, f: 860-650-3374, e: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Conference (names and dates):

4. Presentations/Publications/Teaching Experience

Names and dates:

5. Membership in Professional Organizations

Names and dates:

6. Letter of Recommendation

Submit one letter of recommendation from a practicing hand surgeon or therapist who is a CHT to: Tina Steen, 7 Hunting Ridge Drive, Simsbury, CT 06070

PART III: TO BE COMPLETED BY ALL APPLICANTS

Are you currently under investigation by any professional organization or licensing board?

YES No

Have you ever had your license revoked?

YES No

If you answered yes to either of the above, please explain:

I hereby agree to comply with the constitution and by-laws of the New England Hand Society, and further agree to pay all dues and assessments promptly.

YES, I Agree

Note:

Please be sure to Fax, 860-650-3374, or Email, This e-mail address is being protected from spambots. You need JavaScript enabled to view it :
   • CHT certificate
OR, IF COMPLETING FULL APPLICATION
   • License (OT/PT)
   • Registration (OT/PT)

or Reset