The New York Milton H. Erickson Society for Psychotherapy and Hypnosis (NYSEPH)
NYSEPH GRADUATE REFERRAL APPLICATION
Applicants 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 form with a copy of your Professional Liability Insurance
along with your membership form.
Name______________________________________________________Date___/____/____
Office Addresss____________________________________________________ Zip________
Please specify region and nearest large town, if necessary, in order to facilitate referrals.
Region__________________________Nearest Large Town__________________________
Telephone (Work/Cell)(____)____________________(Home)(____)___________________
E-mail or other contact_________________________________________________________
Degree(s)______________________________________License #_____________________
(If you are a Social Workers, please specify whether you are a LMSW or a LCSW)
Specialty_____________________________________________________________________
Year of Graduation from NYSEPH__________ 2004-2005 Dues Paid? Yes_____No_____
HMO Provider for?___________________________________________________________
Fees__________________Sliding Scale Range_____________________________________
Is there anything else you would like us to know?___________________________________
_____________________________________________________________________________
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.