ASCH Approved Consultant Renewal 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 current License or Certification to practice, with expiration date.
• Certificate of completion of 20 hours of ASCH approved workshop training.

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.

Required Continuing Education

Please upload the following documents on the next page.
• Minimum 20 hours of additional ASCH sponsored or approved Workshop training.
ASCH Approved Advanced Training:
Sponsoring Organization:
Program Title:
Virtual or In Person?:
Completion Date: ?
ASCH Approved Advanced Training:
Sponsoring Organization:
Program Title:
Virtual or In Person?:
Completion Date: ?
ASCH Approved Advanced Training:
Sponsoring Organization:
Program Title:
Virtual or In Person?:
Completion Date: ?

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 as an Approved Consultant, the invoice I receive for dues ($65) will be paid within 15-days of receipt.
   - denotes required fields