| Please provide the following (*) Required |
| First Name:* | |
| Last Name:* | |
| Title: | |
| Name of Practice: | |
| Physical |
| Address:* | |
| City:* | |
| State:* |
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| Zip:* | |
| Mailing (Use same as physical address) |
| Address:* | |
| City:* | |
| State:* |
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| Zip:* | |
| Phone Number:* | |
| Alt. Phone: | |
| Fax Number: | |
| Email Address:* | |
| Web Site: | |
| Tax ID Number:* | |
| Scheduling Method: |
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| Reserved Appointment Times: | |
| Office Hours: | |
| Online Calendar: | |
| Username: | |
| Password: | |
| Therapist Certifications |
1. Certifications*
(Hold down the ctrl key while you click to choose more than one)
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| Other: |
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2. Issues for which you are a qualified and capable care provider.*
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| Other: |
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| Education |
3. Please check any degrees/licenses that you have earned.
(Hold down the ctrl key while you click to choose more than one)
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| Details: |
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| Experience |
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4. How Many years have you been practicing hypnotherapy?*
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| 5. Please describe you work history in the field.* |
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| Philosophy, Style & Affiliations |
6. Please check off the styles and techniques of hypnotherapy you are comfortable using.
(Hold down the ctrl key while you click to choose more than one)
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| Other: |
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7. Please list organizations you are a member of.
(Hold down the ctrl key while you click to choose more than one)
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| Other: |
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| 8. Please describe your philosophy and style regarding the practice of hypnotherapy. |
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| Working Together |
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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. Williams has achieved.... she accomplished... he did..." not "I earned this... or I achieved this...").
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10. Do you have a receptionist? (Executive suite/shared receptionists are fine)
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yes
no
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11. In what kind of facility is your clinic located?
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12. Please give us directions to your clinic from the major highways coming from different directions.
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13. Please list up to three cities (other than the city listed in your address)that are nearby and that clients are usually willing to travel from in order to seek hypnotherapy with you. For example, a business address could be in Encino, CA which is a suburb of Los Angeles. In that case you would include Los Angeles as well as Santa Monica and perhaps Beverly Hills.
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