| Home Address Information |
| |
|
First Name:
|
|
Last Name:
|
|
| Address: |
|
| Address Line 2: |
|
| City: |
|
| Province/State: |
|
| Postal/Zip Code: |
|
| Country: |
|
| E-mail: |
|
| Telephone: |
|
| Home: |
|
| Cell: |
|
| Fax: |
|
| |
|
| Work Address Information |
| |
|
| Company Name: |
|
| Address: |
|
| Address Line 2: |
|
| City: |
|
| Province/State: |
|
| Postal/Zip Code: |
|
| Country: |
|
| E-mail: |
|
| Telephone: |
|
| Work: |
|
| Cell: |
|
| Fax: |
|
| |
|
| Web Site: |
|
| |
| How did you hear about us? |
|
| |
| Area of Specialty or Interest |
|
| |
| Have you ever been convicted of a criminal act? |
Yes
No |
| |
| Please provide details if you answered yes to the above. |
|
| |
| Level Requested: |
|
Training:
List all Related Training. |
|
Membership:
(List all Related Associations you are a member of) |
|
| |
|
| Have you ever had an application to a professional counselling association (including IACH) rejected? |
Yes
No
|
| |
|
| Have you ever had a professional diploma, certificate or license suspended or revoked? |
Yes
No
|
| |
|
| Please provide details if you answered yes either of the above. |
|
| |
|
| Please list the names, addresses, and professional qualifications of at least two hypnotherapy professionals who will serve as your references. |
|
| |
|
| Comment or questions |
|
| |
|
| I certify that the statements made by me in this application are complete to the best of my knowledge and belief. In the event of any complaint or complaints arising which suggest unethical behavior on my part prior to or during the process of application for registration, I authorize the International Association of Counseling Hypnotherapists to both investigate and to consider such information as part of my eligibility for registration. I am aware that by checking this box it is equivalent to my signature.
.Date:
|
| |
| I have read and understand Code of Ethical Conduct, and Standards of Clinical Practice for the International Association of Counseling Hypnotherapists. I am also aware that I am giving consent to the to the IACH to list my name, title, address, phone number,e-mail address, web site and area of specialty on the IACH web site which will be accessible to the general public if and when the IACH deems it appropriate unless I inform the IACH otherwise. I am aware that by checking this box it is equivalent to my signature.
. Date: |
| Please send all documents pertaining to your qualifications to: documents@hypnotherapyassociation.org . Whenever possible, please scan, and e-mail all documents to . Please include your first name in the file name of each document. Send all files as gifs or jpegs. If there are many pages to a document please mail them to the address below. |
| Please note: This application will not be reviewed until payment is received. Thank you for your application to the IACH. |
| |
Application Fee (non-refundable) CAD$25.00 , Membership Fee: Student CAD$50.00, Resident or above CAD$80.00. For U.S. and other denomination conversion please click here.
If paying by credit card on our secure server please follow directions once you click the submit button below.
If paying by cheque please make cheque payable to: IACH,
#1202 1255 Bidwell St. Vancouver, BC Canada V6G 2K8 |
| |
|
