ASCH Dues Renewal 24-25



Please provide the following information:

Member ID:
First Name:
Last Name:
Primary Address:
City:
State:
Zipcode:
Phone:
Email:


Directory
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Please enter up to three specialties from the following list here



License Information

Please indicate the following:
State License:
State Licensing Board:
License Number:
License Expiration Date:



License Agreement
The foregoing information has been voluntarily supplied, with the understanding that it will be review by the ASCH Membership Committee and that, in the process of verification of the facts stated in the application, such facts may become known to third parties, and by checking this box I expressly waive any claim to confidentiality of the material stated herein. I understand that false statements on this application shall be considered sufficient cause for rescinding membership. In addition, I understand that the rules and statutes of the states vary in terms of the use of clinical hypnosis and that the individuals accept responsibility for the care of their clients or patients consistent with the individuals' discipline and licensure, and that they should seek out consultation and/or supervision when in doubt regarding their clinical practices or when questioned by others about their clinical practice.


Payments To ASCH

Membership Dues
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