Member Application - American Psychotherapy and Medical Hypnosis Association

APMHA Membership Application

Please note that information in all fields is required. A fee of $25.00 will be charged for incomplete and non-eligible applications. If you have questions about eligibility, please email us: Click Here

Full Name
E-Mail Address
Highest Degree
License Number
Licensure State
Discipline
Medical or Mental Health License in
Home Address
Home City
Home State
Home Zip Code
Home Telephone
Office Address
Office City
Office State
Office Zip Code
Office Telephone
Birth Date
Web Page URL
School Which Granted Qualifying Degree
School Location
School Phone Number
Hypnosis Training
Total Training Hours
Hypnosis Experience
Total Hours of Experience
Authored Books or Publications:

We receive requests for referrals from our APMHA and 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	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	Addictive Disorders
Medical Anesthesia	Dissociative Disorders	Speech Disorders

Other Issues Treated With Hypnosis:

Use this space for additional remarks

Division Requested (Check one):

I-Doctor	II-Psychotherapist	III-Nursing
IV-Chemical Dependency	V-Social Work	VI-Medical Hypnotherapist
VII-Allied Health Profession	VIII-Forensic Investigation	IX-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.

To charge your membership on our secure ClickBank or PayPal:
(payment links will open in new window)
ClickBank - 2 yr Membership (89.00) or PayPal - 2 yr Membership (89.00)

We will email you within 24 hours to confirm that we have received your payment and application. Outside the United States: ClickBank - $104 or PayPal - $104

Mailed in Applications: $85.00 Two-Year Membership (add $15 outside US) ($25 processing fee for returned applications) There is a small additional fee if you wish to charge your APMHA Membership (above). To pay by check:

Send Application/Check to:

     APMHA
     3430 Creekwood Drive
     Brownsville, TX 78526

Telephone (509) 297-2766 Make checks payable to APMHA Licensed professionals may apply, (few exempt states). Email us with eligibility questions.

Please Type Your Full Name
Enter Today's Date
Professional Reference Name
Years Known
Address
Phone Number

American Psychotherapy and Medical Hypnosis Association
Promoting Ethical Uses of Hypnosis