Website Listing/Referral Information

  Please provide the following contact information (* required):

First Name*
Last Name*
Title
Organization
Office Street Address*
Address (cont.)
City*
State/Province*
Zip/Postal Code*
Country
Work Phone (xxx-xxx-xxxx)*
FAX (xxx-xxx-xxxx)
E-mail*
URL

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Please check any category that applies to your practice:

 

	THERAPY WITH
	individual
	couples
	families
	groups
	business settings

 

 

 

 

 

 

 

 

 

 

 

 

	SPECIALTIES
	addiction
	anxiety
	asthma
	coping with infertility
	dental
	depression
	headaches
	insomnia
	irritable bowel syndrome
	mood disorders
	pain
	past life therapy

	phobias
	preparing for childbirth
	performance anxiety
	smoking cessation
	stress
	surgery
	stuttering
	TMJ
	trauma/PTSD
	trichotillomania
	tourrettes disorder
	weight loss

	AGES SERVED
	preschool
	children
	teenagers
	adults
	geriatric

What other categories would you like to see listed:

Licensing Board*
License Number *

Amount of malpractice insurance . This information will be posted.

Limits of liability * ($ million) /

List memberships                             

(e.g., ASCH, Approved Consultant)     Membership Status:                      

    Full  Associate Student/Resident

    Full  Associate Student/Resident  

    Full  Associate Student/Resident

    Full  Associate Student/Resident

Languages spoken

Types of Insurance accepted    

  Use this space to convey any questions or comments:

By submitting this information to the San Diego Society of Clinical Hypnosis,

you attest that it is true and accurate.