ASCH Individual Consultation Workshop Eligibility Form

This application determines your eligibility for participation in the ICW which is a requirement for ASCH Certification. Required prerequisites: Completion of Level 1 and Level 2 Clinical Workshop training.

Personal Information

First Name:
Middle Name:
Last Name:
Email Address:
Home Phone
Mobile

Professional Information

Degree:
Specialty:
Discipline:
Please enter your Discipline if Other was chosen:
License Number:
State or Province of Licensure:
Date of Expiration: ?
Please provide a list of professional organizations of which you are currently a member of or are eligible for membership:
How long have you been utilizing clinical hypnosis in your professional practice?
In what percentage of your caseload do you use clinical hypnosis?
Memberships
Are you a member of ASCH?
Are you a member of SECH?
Are you a member of ISH?

Prerequisites:

Required Uploads

Your application requires the upload of a series of documents. Once you’ve entered all of required information, click Next to review. Then click Submit where you will be prompted to upload the following documents:
• Level 1 Certificate
• Level 2 Certificate
Please upload the following documents on the next page.
Level 1:
Completion Date: ?
Virtual or In Person?:
ASCH Sponsored?:
Sponsoring Organization (if ASCH approved):
Level 2:
Completion Date: ?
Virtual or In Person?:
ASCH Sponsored?:
Sponsoring Organization (if ASCH approved):
   - denotes required fields