Diploma in Clinical Hypnotherapy

APPLICATION FOR DIPLOMA IN CLINICAL HYPNOTHERAPY
(Please print this page and mail)

Name:____________________________________________________
Address:_________________________________________________
City:____________________________________________________
State:___________________________________________________
Zip:_____________________________________________________
Email:___________________________________________________

I am a Certified Hypnotherapist (C.Ht.)____
I am Certified by________________________________________
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Date of certification:___________________________________
Certification #:_________________________________________
Hypnotherapy Training:___________________________________
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Hypnotherapy Experience:_________________________________
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I certifiy that the above statements are true and I have a minimum of three years experience in the practice of clinical hypnotherapy.

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Signature/Date


Diploma in Clinical Hypnotherapy is $50.00 (check or money order) to:

ACH Board of Examiners
P.O. Box 140182
Dallas, TX 75214