* denotes required information

$25 Processing fee charged for incomplete applications





Name*__________________________________________________________________________





Highest Degree*__________ License*#__________ Discipline*___________ State*____





Medical or Mental Health License in*___________________________________________





Home Address*____________________________ City*_________State*_____ Zip*_______





Home Telephone (     )_________________ Office Telephone (     )_______________





Office Address* ____________________________________State*______ Zip*__________





E-mail Address*___________________________________ Birth date*________________ _____/_____/____





Web Page URL_______________________________ #2_________________________________





School Which Granted Qualifying Degree*________________________________________





School Location* _______________________________Phone*(     )__________________





Hypnosis Training* ____________________________________________________________





_________________________________________________Total Hours___________________





Hypnosis Experience ___________________________________________________________



 

___________________________________________________ Total Hours________________ 





Authored Books or Publications:________________________________________________





_______________________________________________________________________________



We receive requests for referrals from our APMHA & HELP Web Sites.  Please list 

all areas of treatment so that referrals are made to appropriate providers:



Anxiety___  Depression____ Dental Anesthesia____ Phobias ____  Self Esteem_____



Child Birth__ Chronic Pain___ Fears___ Job/Financial Stress___ Concentration___



Trichotillomania____ Nail Biting____ Stop Smoking ____Test Anxiety___ Trauma___



Sleep Problems____ Weight Loss____ Panic Disorders____ Sexual Dysfunction______



Forensic Hypnosis___ Investigation___ Eating Disorders___ Sports Enhancement___



Addictions___ Medical Anesthesia___ Dissociative Disorders__ Speech Disorders__



Other______________________________________________________________________





Division Requested (Check):  I-Doctor____ II-Psychotherapist___ III-Nursing____



IV-Chemical Dependency____ V-Social Work_____  VI-Medical Hypnotherapist_______



VII-Allied Health____ VIII-Forensic Investigation____ IV-Provisional Student___



APMHA Members will represent themselves to the public and to clients truthfully, 

with regard to areas of expertise.  Specialty designations will be based on 

accredited training.  No false or misleading claims shall be made publicly or 

in private consultations.  Members will make appropriate referrals when client 

issues are beyond the scope of training, or they will obtain supervision for 

educational purposes, with prior consent of the client. No Claims of guaranteed 

results shall be represented to the public, and making claims not based upon 

documented valid research shall be considered a violation of ethical practices. 





I agree to abide by the APMHA Ethical Standards, by representing myself and my 

experience accurately with clients and colleagues, and to use appropriate methods 

of referral and/or supervision when treatment is beyond the scope of my training/

expertise.  I further agree to keep informed of the Laws and State Statues 

regarding the use of hypnosis in order to protect the welfare of  clients/others 

who may be compromised for ethical/legal reasons.





Signature___________________________________________________ Date______________



Professional Reference Name:________________________________ Years Known_______



Address ______________________________________________ Phone (      )__________ 



Address _______________________________________________________________________