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Oregon Society of Clinical Hypnosis Membership Application

Promoting excellence in the use of hypnosis
OSCH is composed of licensed health care professionals who use hypnosis in clinical practice with a mater's or doctorate (medical or mental health)degree. Membership is also offered to residents, interns in an academic program, and students in training who are in graduate or advanced degree programs. Our focus is in promoting the use of clinical hypnosis through education and professional development. Full details of membership eligibility and membership categories is on our website: www.oregonhypnosis.org.

To apply for membership please complete all applicable questions below.

Thank You

~The OSCH Leadership Team
Name*

First NameLast Name
Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing Address if different from above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Work Number*

Area CodePhone Number
Cellular Number

Area CodePhone Number
Home Number

Area CodePhone Number
E-mail*
Membership Category*

RegularAssociate Member (student, intern, resident, etc)RetiredLifetime (20+ years in OSCH)
Health Care Practice Area*
Board License or Certification #1*

License/Certification TypeLicense/ Certification #
Board License or Certification #2

License TypeLicense/ Certification #
Website to verify license or certification*
Education and Training:

Please provide information about your academic training and current area of healthcare practice
What is the highest level of education you have completed?*
What is your current position/role in healthcare?*
Hypnosis Specific Training & Experience:

If your hypnosis training or certification is from a non OSCH, ASCH, or ASCH component section organization please provide information in the "Other" fields.
How did you hear about OSCH?*
Hypnosis Course Level Completed

Basic TrainingIntermediate TrainingAdvanced TrainingOther
Hypnosis Certification

ASCH CertificationASCH Approved ConsultantDiplomateOther
Other Hypnosis Training, Experience or Certification
Students, Residents, Interns, please provide information on your academic program
*Student must provide proof of student status when requested. Include program name and contact information for program administrator or instructor.
Attestation*

I meet the criteria listed for the membership level I am applying forI agree to abide by the OSCH code of ethicsI am a member in good standing and abide by my regulatory board requirementsAll information provided is accurate to the best of my knowledge
Date of Application*

MonthDayYear
Signature, hold down your right mouse button or track pad to sign*
E-mail
E-mail*
Should be Empty:

Oregon Society of Clinical Hypnosis Membership Application