Application Form - Dr Leah Hechtman

Application Type

Practitioner

Clinic

Practitioner Details

Full Name (as to appear on certificate)*

First Last

Preferred Name

Email Address*

Phone*

Country*

Country

Time Zone

Time zone you will be in for the office hours sessions.

Clinic Group Details

Clinic Name*

Clinic Address*

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

Clinic enrolments get a discount for 2 or more practitioners. List the practitioners to be enrolled below:

Enrolments per Practitioner	Discount	Fee*	Options
1	0%	$11,500 AUD	As per individual enrolment
2	5%	$10,925 AUD	Upfront or semester split
3–4	10%	$10,350 AUD	Upfront or semester split
5+	15%	$9,775 AUD	Upfront only
*Incl. GST. Single grouped invoice.

List of Practitioners

First Name

Last Name

Title

Email Address

Clinic Practitioners Proof of Training

Upload Proof of Training Certificates for all the practitioners listed above.

Drop files here or

Max. file size: 5 MB.

Professional Background

Current Occupation / Professional Title

Current Qualifications*

Please list your current qualifications (include institution and year)

Proof of Training*

Upload your proof of training documents

Drop files here or

Max. file size: 5 MB.

Professional Registrations*

Professional Registrations (AHPRA, ANTA, etc.)

Years in Clinical Practice

Please enter a number less than or equal to 50.

Main Areas of Focus

What areas of focus do you specialise in? (e.g. fertility, gynaecology, obstetrics):

Current Practice Setting

Solo, group, telehealth, etc.

Current Enrolment

Are you currently enrolled in or a graduate of another course with Leah Hechtman?

Yes

No

Please specify your current enrolment with Dr Leah Hechtman

Course Selection

Advanced Fertility Certification

Integrative Gynaecology Certification

Integrative Obstetrics Certification

Foundational Fertility Certification

Alumni Enrolment

Eligibility & Commitment

What draws you to this program?

What outcomes do you hope to achieve through this training?

How will you integrate this learning into your professional practice?

Do you anticipate any barriers to completing the course (time, access, technology)?

How did you hear about the course?

Terms, Policies & Agreements

I have read and understood the course outline and time commitments.

I acknowledge that course materials are for educational purposes and not a substitute for medical care.

I understand that all materials are copyright of Dr Leah Hechtman and may not be reproduced or shared.

I agree to maintain confidentiality within course discussions and case presentations.

I agree to uphold professional conduct and respectful communication during all live sessions and group forums.

I understand that refunds or deferrals follow the published Course Policies.

I consent to receive course-related emails and updates from Leah Hechtman.

By submitting this application, I confirm that the information provided is accurate to the best of my knowledge and that I am ready to engage fully in this educational experience with professionalism, curiosity, and respect.

2026 Application Form