Apply Now to Become an AHC Affiliate Member
Congratulations on your decision to apply to become an American Hypnosis Clinic Affiliate. If you are chosen, we will include you in our database so you can benefit from our nationwide marketing. This leaves you open to do more of the therapy you love and less sales.
We do not charge you anything for this service. We are paid entirely by the client.
You will be assigned a rankings score that will increase or decrease depending on client feedback for the quality of work you do with your clients. The therapists with the highest rankings have more clients referred to them.
We choose a limited number of therapists in each area. If you qualify but are not chosen, we will keep your information on a list in case an opportunity opens up at a later date.
Please fill out one application for each therapist in your practice. Everyone can be an affiliate if they all qualify. Please also include a photo of your office exterior and therapy room.
You may choose to withdraw from membership at any time for any reason and we reserve the right to terminate your affiliation at any time as well.
As an affiliate you will benefit from our marketing, patients referred directly to you, opportunities to grow your business through shared advertising/promotional materials, classes, products and a community of like-minded professionals working together to elevate the art and science of hypnotherapy.
Good luck, and hopefully we will be working together to help those in need on a regular basis.
Application
Please print the following application, complete and fax back to
(804) 594-1971.
Full Name:
Address:
Phone:
Alt. Phone:
Fax:
Email:
Website:
Therapist Certifications
1. Certifications – Circle all that apply:
MHt
CH/Cht
Hypnosis Trainer Certification
NLP Practitioner
NLP Masters
NLP Trainer
No Certification
2. Issues for which you are a qualified and capable care provider – Circle all that apply:
Alcoholism
Anger Management
Childbirth w/ less Pain
Drug Self-Control
Emotional Eating Behaviors
Emotional Self Improvement
Fibromyalgia
Gambling
High Blood Pressure
Irritable Bowel Syndrome
Learning Improvement
Memory Improvement
Morning Sickness
Motivation
Obsessive Compulsive Behavior
Pain Management
Phobia
Regression
Self Esteem
Sexual Dysfunction
Sleep Disorders
Speech Impediment
Sports Attainment
Smoking Cessation
Stress/Anxiety
Tinnitus
Weight Loss
Other:
Education
3. Please list any degrees, certifications or licenses you have earned and send us a copy of them:
Experience
4. How many years have you been in practice?
5. Please describe your work history in the field:
Philosophy, Style and Affiliations
6. Please circle the styles and techniques of hypnotherapy you are comfortable using:
Ericksonian Hypnosis
Elman-style Hypnosis
Autogenic-Style Hypnosis
NLP
Biofeedback (GSR)
Reality Therapy
Biofeedback (EEG)
Emotional Freedom Technique (EFT)
Parts Therapy
Cognitive Behavioral Psychology
Regression
Rational Emotive Therapy
Other:
7. Please List any organizations you are a member of:
8. Please describe your philosophy and style regarding the practice of hypnotherapy.
9. Please write a one or two paragraph summary of your qualifications we can pass along to prospective clients and for marketing purposes. Please write it in the second person perspective. (ie: “Dr. Smith has accomplished…”)
10. Do you have a receptionist?
11. In what kind of facility is your clinic located? Please circle one:
Home
Single business office
Multi business office building
In partnership with another health-related practice
Other (please list)
We require a photo of the exterior of your office and the therapy space.
12. Please give us directions to your clinic from the major highways coming from different directions