To apply, please fill out this form, print it, and send it along with your check and relevant documents to: FSCH, 8227 SW 82 Place., Miami, FL 33143. Or, for your convenience, you may pay for your membership dues online, by clicking the appropriate button below. If you have any questions please call 305-598-9992, or 1-800-239-3364 in Florida.
_____________________FSCH Membership Application
Name: ____________________________________________________________
Degree: _________ License #: ___________________ State: _____________
Profession:____________________________________________________________
Address: ___________________________________________________________
If you'd like to be in the Online Diectory, please give us only an address you are comfortable having published. Publish? ____ Don't publish? ____ City: ___________________________________________________________
State: _______ Zip Code:_______________ County:___________________
Work Phone: _____________________ Home Phone:________________________
Fax: ______________________ E-Mail:_____________________________
Education
Graduate School: __________________________________________________________
Major: _________________________ Date Graduated: _________________
Comments: ___________________________________________________________
Professional Memberships
I am a member of ASCH _____ Status:______________________ Date:_________
I am a member of SCEH _____ Status:______________________ Date:_________
Professional Organization Memberships: ____________________________________
_______________________________________________________________________
Other Hypnosis Organization Memberships: __________________________________
Qualifications
Certifications, Board Certified Status, Awards, Fellowships, etc. ________________
_______________________________________________________________________
Hypnosis Training _________________________________________________________
If you'd like to be included in the Online Directory, please add the following, and sign and date this section:
Specialty Areas of Practice _________________________________________________
Languages Fluent In _______________________________________________________
Insurances you accept ______________________________________________________
Signature:_________________________________________ Date:___________________
Membership Level Requested:
__ $65 Member __ $65 Associate Member __ $25 Student Member
Please note: Membership is dependent upon review and acceptance of completed application, including copies of license, degree, and relevant training. Student applicants also require a letter from Department Chair confirming status. After the process is completed, you will receive a certificate.
I have read and agree to abide by the FSCH Code of Ethics.
Signature: _______________________________________ Date: _________________
