NYSEPH Membership Form

The New York Milton H. Erickson Society for Psychotherapy and Hypnosis (NYSEPH)

NYSEPH MEMBERSHIP/REFERRAL FORM for 2008-2009

Membership in NYSEPH is open to all those who are interested in hypnosis. The Membership fee is $75.00 per year from September through August but free for current NYSEPH students. Membership in NYSEPH provides you with the following benefits:

NYSEPH graduates can be listed on our website's referral page.
Discounts to conferences and workshops.
Use of our extensive lending library of videos and DVDs.
Free seminars for members only.
Advertise on our Bulletin Board

To join NYSEPH or to renew your membership and application to the referral page, please fill out this form, the referral section for members who are eligible to be listed on the website, include a copy of your current Professional Liability Insurance and mail these with a check of $75.00 payable to NYSEPH to:

Brigitte E. Lifschitz, LCSW
30 West 60th Street, # 1R
New York, NY 10023
Tel.# 212-245-4121

Name_________________________________________________________Date___/____/_____

_Home Address__________________________________________________________Zip_____________

_Office Address___________________________________________________Zip_____________
Please check preferred mailing address.

Telephone (Work/Cell)______________________________(Home)_________________________

E-mail______________________________________________________________________

Please fill out if you are applying for referral listing.
Specify region and nearest large town, if necessary, in order to facilitate referrals.

Region__________________________Nearest Large Town__________________________

Private Practice Address_____________________________________________________________________

HMO Provider for?___________________________________________________________

Fees__________________Sliding Scale Range_____________________________________

Specialty_____________________________________________________________________

Year of Graduation from NYSEPH__________ 2008-2009 Dues Paid? Yes_____No_____

Degree(s)______________________________________License #_________________________
Social Workers, please note whether you are a LMSW or LCSW.

Hypnosis Training and Experience__________________________________________________________

Primary Affiliation//Agency_________________________________________________________

Is there anything else you would like us to know?___________________________________

_____________________________________________________________________________

How did you hear about NYSEPH?
Website________Journal ad______Recommendation___________Other____________________

Applicants for the referral page must be graduates of NYSEPH who are currently members. In order to be added to or to remain on the referral page, you must send in this membership form with a copy of your Professional Liability Insurance.

In order to be listed on NYSEPH's referral page, you must enclose proof of Professional Liability Insurance (e.g. copy of cover page) every year. Social Workers need to send in a copy of their new License.