FSCH

The Florida Society of Clinical Hypnosis

Membership Application

To apply, please fill out this form, print it, and send it along with your check and relevant documents to:  FSCH, 13705 SW 91 CT, #C, Miami, FL 33176.  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.

__________________

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? ____

       If you were referred by a current member, please provide the member's name:

        ______________________________________________________________________

      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: _________________

    $65 Member

   $65 Assoc. Member

 $25 Student Member

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