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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 Name Last Name
Office Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Mailing Address if different from above

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Work Number

Area Code Phone Number
Cellular Number

Area Code Phone Number
Home Number

Area Code Phone Number
E-mail *
Membership Category *

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

License Type License/ Certification #
Board License or Certification #2

License Type License/ Certification #
Website
Hypnosis 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 Training Intermediate Training Advanced Training
Hypnosis Certification

ASCH Certification ASCH Approved Consultant Diplomate
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 for I agree to abide by the OSCH code of ethics I am a member in good standing and abide by my regulatory board requirements All information provided is accurate to the best of my knowledge
Date of Application *

Month Day Year
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