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Please provide the following information:
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Personal Information
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First Name: | |
Middle Name: | |
Last Name: | |
Credentials: | |
Email Address: | |
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Company Information
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Company Name | |
Job Title: | |
Address | |
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City | |
State | |
Zip | |
Work Phone | |
Work Fax | |
Website | |
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Home Address
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Address | |
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City | |
State | |
Zip | |
Home Phone | |
Mobile | |
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Primary Address
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Please indicate ONE address where you would like to receive all mailings:
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| COMPANY Address is Primary Address |
| HOME Address is Primary Address |
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Directory
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Please indicate below if you do NOT wish for your information to be listed in the online Membership Directory:
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| Directory Opt Out |
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Required Uploads
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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:
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• A copy of your current License or Certification to practice, with expiration date.
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• A copy of your official university transcript for the highest degree earned.
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• The Certificates of Completion for ASCH sponsored/approved Level 1 and Level 2 Clinical Hypnosis Workshops.
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• The signed Consultation Contract and Verification Form showing completion of the required 20 hours of individualized consultation training. This document can be found here.
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• 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.
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Degree Information
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A copy of your official transcript must accompany your application.
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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.)
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Degree: | |
Field: | |
University: | |
City & State of University: | |
Year of Graduation: | |
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Licensure
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A copy of your current license or certification to practice, with expiration date, must accompany your application.
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Field: | |
License Number: | |
State or Providence of Licensure: | |
Date of Expiration: | ?
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Professional Memberships
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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. | |
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Letters of Recommendation
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Letters of recommendation must accompany your application.
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• 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.
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Required Continuing Education
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Certificates of completion and signed Learning Contract forms must accompany your application.
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Training
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ASCH Approved Level 1 Clinical Hypnosis Workshop:
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Sponsoring Organization: | |
In Person or Virtual?: | |
Completion Date: | ?
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ASCH Approved Level 2 Clinical Hypnosis Workshop:
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Sponsoring Organization: | |
In Person or Virtual?: | |
Completion Date: | ?
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ASCH Individualized Consultation Training:
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Approved Consultant(s): | |
Number of one-on-one hours: | |
Number of small group hours: | |
Dates: | |
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Attestations
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I attest to the following:
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| 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. |