Name and Degree:_______________________________________________________
Business/Title:________________________________________________________
Office Address: _______________________________________________________
_______________________________________________________________________
Home Address: _________________________________________________________
_______________________________________________________________________
Phone: (office) ________________________ (home) _______________________
E-mail: _____________________________Fax:______________________________

Professional Licensure: _______________________________________________

Education (list Graduate and last Undergraduate Institutions attended, 
date completed and field of study):____________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Formal Training in Clinical Hypnosis (dates, hours, sponsoring
organization): ________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Additional Training or Experience in Clinical Hypnosis: _______________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Professional Organizations (please include start date of membership): 
_______________________________________________________________________
(note: ASCH and SCEH members automatically qualify for CSCH membership)

Programs you would like CSCH to offer: ________________________________
_______________________________________________________________________
_______________________________________________________________________
Presentations you are willing to offer:________________________________
_______________________________________________________________________
_______________________________________________________________________

    Please forward completed form plus check made out to the Chicago Society of Clinical Hypnosis for $50 for the 2007-2008 membership year ($25 for qualified students) to Dr. Edward J. Frischholz, 6301 N. Sheridan #23G, Chicago, IL 60660.

    If we are unable to process your membership for any reason, your check will be returned to you.

    *Renewing Members: Please be kind enough to fill in changed or new information.

    Thank you for your patience as we try to improve this organization!

    To print this form, simply highlight the text, copy it to the clipboard, open notepad, paste it there, and select file|print. It may be slightly misaligned if you use programs other than notepad.