ASCH Initial Certification Application

Please provide the following information:

Personal Information

First Name:
Middle Name:
Last Name:
Credentials:
Email Address:

Company Information

Company Name
Job Title:
Address
City
State
Zip
Work Phone
Work Fax
Website

Home Address

Address
City
State
Zip
Home Phone
Mobile

Primary Address

Please indicate ONE address where you would like to receive all mailings:
COMPANY Address is Primary Address
HOME Address is Primary Address

Directory

Please indicate below if you do NOT wish for your information to be listed in the online Membership Directory:
Directory Opt Out

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:
• A copy of your current License or Certification to practice, with expiration date.
• A copy of your official university transcript for the highest degree earned.
• The Certificates of Completion for ASCH sponsored/approved Level 1 and Level 2 Clinical Hypnosis Workshops.
• The signed Consultation Contract and Verification Form showing completion of the required 20 hours of individualized consultation training. This document can be found here.
• Two letters of endorsement, including one from the Approved Consultant providing your individualized training, and the other from a professional colleague who can comment on your character, professional ethics, and use of hypnosis.

Degree Information

A copy of your official transcript must accompany your application.
Please provide the following from your most advanced degree: (You must have at the least a Master's Degree in an appropriate health care field.)
Degree:
Field:
University:
City & State of University:
Year of Graduation:

Licensure

A copy of your current license or certification to practice, with expiration date, must accompany your application.
Field:
License Number:
State or Providence of Licensure:
Date of Expiration: ?

Professional Memberships

Please provide the name of a professional organization relevant to your degree that you belong to:
If you are not a current member of a professional organization relevant to your degree, please include a statement below indicating that you are eligible to join, but choose not to.

Letters of Recommendation

Letters of recommendation must accompany your application.
• Two letters of endorsement, including one from the Approved Consultant providing your individualized training, and the other from a professional colleague who can comment on your character, professional ethics, and use of hypnosis.

Required Continuing Education

Certificates of completion and signed Learning Contract forms must accompany your application.
Training
ASCH Approved Level 1 Clinical Hypnosis Workshop:
Sponsoring Organization:
In Person or Virtual?:
Completion Date: ?
ASCH Approved Level 2 Clinical Hypnosis Workshop:
Sponsoring Organization:
In Person or Virtual?:
Completion Date: ?
ASCH Individualized Consultation Training:
Approved Consultant(s):
Number of one-on-one hours:
Number of small group hours:
Dates: ?

Attestations

I attest to the following:
The information provide in this application is accurate and complete.
I agree to accept the ASCH Code of Conduct.
I fully understand the rules and statutes in the state(s) where I am licensed vary as it relates to the use of clinical hypnosis.
The use of hypnosis will only be used within the scope of my practice.
If I am accepted for certification, the invoice I receive for certification dues ($150 for ASCH members; $300 for Non-Members) will be paid within 15-days of receipt.
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