ASCH Certification Renewal Application

Please provide the following information:

Personal Information

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

Company Information

Company Name
Job Title:
Work Phone
Work Fax

Home Address

Home Phone

Primary Address

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


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 current License or Certification to practice, with expiration date
• The Certificates of Completion for 20 hours of ASCH sponsored or approved Workshops.


Please upload a copy of your current license or certification to practice, with expiration date in the space provided after you click Submit.
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.

Required Continuing Education

Certificates of completion must accompany your application.


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 ($65 for ASCH members; $125 for Non-Members) will be paid within 15-days of receipt.
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