i. Please review the ASCH Code of Conduct. Completion of this application includes your attestation that you agree to abide by this code.
ii. Print and complete the form below.
iii. Mail the form with your check for $60 and a copy of your current license to: NCSCH ℅ Terry Robertson, LCSW, 3002 Bridges Street, Morehead City, NC 28557
(If you are a student applicant, please enclose a letter from your graduate school attesting to your full-time status and make your check for $25.)
Full Name Professional License Number:
ASCH Member? Yes No If yes, what year did you join?:
ASCH-Approved Consultant? Yes No
ASCH Certified? Yes No
Student? Yes No Requires letter from graduate school confirming full-time status.
List Your Services for the Public
Fill out this form to request your member listing profile at the North Carolina Society of Clinical Hypnosis.
First Name: *
Last Name: *
ASCH Member?: *
ASCH Certified?: *
ACSH-Approved consultant?: *
Business Address 1: *
Business Address 2:
Zip Code: *
(if OK to be contacted by public that way) i.e. firstname.lastname@example.org
Description of Practice: *
50 word maximum description of your practice.