Electronic Membership Renewal

 













Please enter up to three specialties from the following list




LICENSE INFORMATION (REQUIRED): 

 


Required field: Please list the state that issued your license.

________________________________


Required field: Please list the state licensing board.

________________________________


Required field: Please list your license number.

________________________________


Required field: When does your license expire?


LICENSE AGREEMENT:

The foregoing information has been voluntarily supplied, with the understanding that it will be review by the ASCH Membership Committee and that, in the process of verification of the facts stated in the application, such facts may become known to third parties, and by checking this box I expressly waive any claim to confidentiality of the material stated herein.  I understand that false statements on this application shall be considered sufficient cause for rescinding membership. In addition, I understand that the rules and statutes of the states vary in terms of the use of clinical hypnosis and that the individuals accept responsibility for the care of their clients or patients consistent with the individuals' discipline and licensure, and that they should seek out consultation and/or supervision when in doubt regarding their clinical practices or when questioned by others about their clinical practice.


PLEASE SELECT THE APPROPRIATE ITEM(S) BELOW:



To select multiple options hold down the Ctrl button (Windows) or Cmd button (Mac) and click on each option you wish to select

 

 

 

 

 

 


PAYMENTS TO ASCH:


Your ASCH dues have been auto-filled based on your membership status the previous year. If you would like to request a change in status, please contact Doris Bowens at the ASCH Central Office via email (membership@asch.net) or by phone at (630) 980-4740. Please note all amounts below are in USD.

IMPORTANT - For your convenience, the American Society of Clinical Hypnosis (ASCH) will be making all dues transactions via credit card an annual recurring charge UNLESS you indicate that you do NOT want the society to do that.  If you would prefer that the charge to your credit card be a ONE TIME charge, please check the box below before payment.  Thank you.   









*Contributions or gifts to the American Society of Clinical Hypnosis are not tax deductible as charitable contributions.  However, they may be tax deductible as ordinary or necessary business expenses.  Please consult your tax advisor for specific guidance. Tax ID: 36-2418823



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