Directions:

 

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:

 

Address 1:

 

Address 2:

 

City:

 

State:

 

Zip Code:

 

email:

 

 

Website:

 

 

Main Phone:

 

 

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.

 

Personal Information

First Name: *

 

Last Name: *

 

ASCH Member?: *

Yes

No

 

ASCH Certified?: *

Yes

No

 

ACSH-Approved consultant?: *

Yes

No

 

Practice Information

 

Business Address 1: *

 

Business Address 2:

City: *

 

State: *

 

Zip Code: *

 

Phone Number:

i.e 919-333-4444

 

Fax:

i.e. 919-222-3333

 

email:

(if OK to be contacted by public that way) i.e. john@doetheraphy.com

 

Website url:

i.e. http://www.nchypnosis.org/

 

Description of Practice: *

50 word maximum description of your practice.