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

 


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.

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Copyright 2009 San Diego Society of Clinical Hypnosis. All rights reserved.
Last updated: 07/24/2013