North Carolina Society of Clinical Hypnosis

Your Name *


Professional Title (LPC, LCSW, LMFT, etc.) *


Are you Licensed? *
Yes No

If yes, please provide Professional License Number and Board Name


Are you a Student? (Requires letter from graduate school confirming full-time status.) *
No Yes

If yes, please attach a copy of confirmation letter here:


Your Email *


Phone *


Street Address *


City *


State *


Postal Code *


NCSCH Member? *
No Yes