NYSEPH MEMBERSHIP/REFERRAL FORM for 2009-2010

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

Brigitte E. Lifschitz, LCSW
NYSEPH Membership
P.O. Box 876
New York, NY 10024-0540
Phone # 212-877-1931; ...E-mail: nysephinfo@earthlink.net

PLEASE PRINT CLEARLY

Name.....................................................................................Date ........../............./..............

Home Address.................................................................................................Zip....................

Office Address................................................................................................Zip.....................
......Please check preferred mailing address

Home Phone # ......................................................Work/Cell #.......................................

E-mail...............................................................................................................................

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

Hypnosis Training and Experience..........................................................................................................................................................................

Primary Affiliation: Private Practice/Agency..................................................................................................................

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

..................................................................................................................................................................................................

How did you hear about NYSEPH? Website, Journal ad, Recommendation, Other............................

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............................................................................................................Zip............................

HMO Provider for?........................................................................................................................

Fees.....................................Sliding Scale Range......................................................................

Specialty...................................................................................................................................

Year of Graduation from NYSEPH.....................2009-2010 Dues Paid? Yes No