Referral Program Application

IN ORDER TO QUALIFY, YOU MUST MEET THESE THREE CRITERIA:

Must be a certified HYPNOTHERAPIST and have obtained that certification from an accredited institution/university.
Must be a member of a professional association (American Hypnosis Association, American Counselors Association, etc.)
Must be certified in a minimum of two specialty areas. (PTSD, ADD, Anxiety, Phobias, Weight Loss, Smoking Cessation, etc.)

Name (as listed on your certification)(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone number(Required)

Email(Required)

Company name(Required)

Website

Office address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Office phone number

Languages spoken(Required)

Hypnotherapy Specialties

Metaphysical Specialties

Years/Months of Experience(Required)

University/Institute Attended(Required)

Institute’s address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Institute’s phone number(Required)

Accredited institute?(Required)

Yes

Date began(Required)

Date of graduation(Required)

GPA(Required)

Continuing Education

Certifications/Licenses(Required)

Memberships

Why did you become a certified hypnotherapist and/or metaphysical practitioner?(Required)

Hypnotherapist Referral Service