Registration 2 - Mindful Guide Consulting

The deadline for applications is October 27th, 2017.

Yearly Membership Fee is $450 CAN and can be paid using the form below after you have filled out the details.

If at any point in time you need to save your form answers and return, click on “save and continue” at the bottom of this page. Make sure you save the link! If you have any questions about the process or encounter any problems while filling out your form, email Lisa Palasti at lisapal@sympatico.ca.

Your Personal Information
This section is for your personal information for our personal and payment records. This is not information that will be posted on the website and given to the public.
Name*
Prefix First Last
Personal Email*
Personal Phone*
Information for Website
This following information is for the public RDI Canada Coalition Website.
Name*
Please write your name exactly as you would like it to appear on the RDI Canada Coalition website. Include any titles that you would like to appear beside your first name. Example: Jane Doe PhD., RDI Certified Consultant, SLP
Qualifications
List all titles, degrees, certifications and qualifications that you would like to be added to your profile page.
Contact Email*
Client contact email
Contact Phone Number
Client contact phone number.
Address
Office address (If you do not have an office you can fill this is with the address you see clients at now. If you do not have one, or wish to not have an address appear on your profile, skip this step.)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Areas Serviced*
Please list all cities/provinces/locations that you service, separated by commas.
Website Address
If you have a business website please add the URL here.
Blog Links
In order to make the RDI Canada Coalition site more informative and robust, we need blog posts! If you have already written blog posts that you would like to be posted on the launch date please enter the url below. If entering more than one, separate each with a comma.
Social Media
Please add the URL for any social media accounts (Facebook, Linkedin, etc.) you would like added to your profile. If entering more than one, please separate URLs with a comma.
At a Distance*
Do you offer work at a distance via online meetings such as Skype, Zoom or Google Hangouts?
- Yes, I offer at a distance work
- No, I only work in my area
Biography*
Add your personal biography here (3-4 paragraphs).
Do you want headshot attached to your profile on the public website?*
- No, I do not want to add a picture of me
- Yes, I would like to upload a headshot image
I understand and agree to continue knowing that I have not provided you with an image to be used in my public profile.*
(if you do not agree, please go back to the last question and upload a headshot.)
- Yes, go forward
Professional Headshot
You can upload the professional headshot image that you want on your public profile here. *In order to get a clear, non pixelated image on a website, it needs to be large enough. Please upload a good quality image that is at least 400pxl by 400pxl. If you give us an image that is too small, we can not guarantee a clear image.
Drop files here or

Accepted file types: png, pdf, jpg, .
I understand that if I uploaded an image smaller than 400 by 400 pixels it will not show up as a clear image on the public website.*
- Yes, I understand
I confirm that all of the information listed above is correct and that any items left blank will not appear on the public website for the RDI Canada Coalition. I understand and agree that my personal information on the website can only be changed and/or corrected no more than two times within the one-year contract agreement.*
- Yes, I agree and understand
- No, I do not agree
If you do not agree to these terms and would like more information, please email Lisa Palasti at lisapal@sympatico.ca

Save and Continue Later

Your Personal Information

Information for Website