CSCH Membership Application – The Colorado Society of Clinical Hypnosis

Membership Type

Please indicate the membership level for which you are applying.

Details about membership types can be found on the _____ page.

Personal Information

First Name

Last Name

Credential(s) (MD, DO, Ph.D., Etc.)

Company/Clinic/School Name

Job Title

Professional Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone

Fax

Website

Education

Your most advanced clinical degree (from an accredited university) and field in which it was granted:

Licensure

Your current license number, expiration date, and online location where it can be confirmed (Dora, etc.)

Referral

Were you referred by a current CSCH member?

Additional Material

• Certificates of completion for any hypnosis training you have taken (one 20 hour ASCH‐approved course required for Full membership), or proof of ASCH membership. • Include a short statement on your interest in hypnosis.

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