ASCH Initial Approved Consultant 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
• A copy of your official transcript
• Certificate of completion for the following: T&C Workshop, 20 hours of ASCH approved level 1 training, 20 hours of ASCH approved level 2 training, and an additional 40 hours of ASCH approved advanced workshop training
• Learning Contract with Approved Consultant and 20 hours of individualized consultation training. This document can be found here.
• One letter of endorsement from a professional colleague who can comment on your clinical demeanor including exercise of judgement and professional ethics, use of hypnosis, and character. 

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

Please upload the following documents on the next page.
• One letter of endorsement from a professional colleague who can comment on your clinical demeanor including exercise of judgement and professional ethics, use of hypnosis, and character.

Required Continuing Education

Please upload the following documents on the next page.
• Proof of completion of 10 hour Teaching and Consultation (T&C) Workshop.
• Minimum 40 hours of additional ASCH sponsored or approved Advanced Workshop training.
• Learning Contract with Approved Consultant and 20 hours of individualized consultation training. This document can be found here.
Training
Teaching and Consultation (T&C) Workshop:
Sponsoring Organization:
Program Title:
In Person or Virtual?:
Completion Date: ?
ASCH Approved Level 1 Clinical Workshop:
Sponsoring Organization:
Program Title:
In Person or Virtual?:
Completion Date: ?
ASCH Approved Level 2 Clinical Workshop:
Sponsoring Organization:
Program Title:
In Person or Virtual?:
Completion Date: ?
ASCH Individualized Consultation Training:
Approved Consultant(s):
Number of one-on-one hours:
Number of small group hours:
Completion Dates: ?
ASCH Approved Advanced Training:
Sponsoring Organization:
Program Title:
In Person or Virtual?:
Completion Date: ?
ASCH Approved Advanced Training:
Sponsoring Organization:
Program Title:
In Person or Virtual?:
Completion Date: ?
ASCH Approved Advanced Training:
Sponsoring Organization:
Program Title:
In Person or Virtual?:
Completion Date: ?

Additional Requirements

I have a minimum of 5 years of independent practice utilizing clinical hypnosis.
I have a minimum of 5 years of membership in ASCH.

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 ($150) will be paid within 15-days of receipt.
   - denotes required fields