Connie Jo Holmes | Hypnosis Certification Intake Form

ICBCH New Member Certification Form

Please complete the required information for certification with the ICBCH plus certification from BU2BFULL, Inc.

Legal Name(Required)

Name as you want it to appear on your certificate(Required)

Address(Required)

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

Phone(Required)

Email(Required)

Education (this is for our knowledge and tracking):

List Your Highest Academic Degree:(Required)

Name of School(Required)

Year of Graduation(Required)

Please list any professional licenses/certifications:

Certification Details

For CPH: "Certified Professional Hypnotist (C.P.H.) Requirements for this level of certification include completion of an ICBCH approved training. Attach documentation of your training hours if you are applying through reciprocity and completed your certification through another organization."

For CCH: "Certified Clinical Hypnotherapist / Advanced (C.C.H./AC) The ICBCH will award status as a Certified Clinical Hypnotherapist / Advanced standing only to those who are certified or licensed by a state or recognized national board in healthcare, medical or mental health professions, who have completed at least 100 hours of approved coursework. Must provide your state licensure/certification documentation. The ICBCH recommends even those who are licensed use the title, Certified Professional Hypnotist rather than Certified Clinical Hypnotherapist for a variety of reasons, including differentiating our profession from psychotherapy, and because in marketing, people are looking for a hypnotist, not a therapist."

NOTE: We recommend CPH (Certified Professional Hypnotist) for all members.

Which Level of Certification are you applying for through the ICBCH (NOTE: Unless you hold a mental health license, Certified Professional Hypnotist is recommended/required).(Required)

CPH: Certified Professional Hypnotist

CCH: Certified Clinical Hypnotherapist

Legal Details

(NOTE: Although a prior felony conviction will not automatically disqualify one for certification, any person with a prior felony conviction for moral or sexual crimes against children, or sexual violence against adults, or other felonies as deemed inappropriate for certification by the ICBCH will not be certified by the ICBCH. Failure to disclose criminal history will result in revocation of credentials, and is an act of perjury. If you have questions on this policy, please contact our office prior to completing the course materials.)

Have you ever been convicted of a felony?(Required)

Yes (if yes, please email cholmes@conniejoholmes.com to schedule a phone call)

Have you ever had a professional license or certification revoked, suspended or denied in any state or by any certification board?(Required)

Yes (if yes, email cholmes@conniejoholmes.com to schedule a phone call)

Read and Acknowledge

I hereby certify that the information provided above is true and accurate. I am applying to receive recognition as a hypnotist/hypnotherapist. I understand that this certification recognizes specialized training in the required subject matter and does not provide the authority to or client services apart from the existing requirements of my state of residence. I agree to practice within the scope of my education, experience and training and to provide client services consistent with the ethical standards of ICBCH, my respective professional designation(s), and within state law. Certification certificates remain the property of the ICBCH and must be surrendered in the event of revocation by the Board.