Independent Practitioner Application Form

Step 1: Fill out the form below and click Submit.

Step 2: Click the Paypal button to submit the application fee ($197 $155 through 2014)

Your application will be considered when both steps have been completed.

All Fields Are Required.

Your Name

Your phone number

Your Email

Your Website

Where do you practice? I.e. name of the wellness center, office, medical center, or organization where you work.

What are your credentials? List your degrees, certifications, etc.

What services do you provide?

How are your services offered? Check all that apply.

How do potential clients make appointments with you? (eg. Email, phone, form on your website, etc.)

How do you communicate with clients between appointments? (eg. email, Skype, phone, text, etc.)

What is your fee policy? E.g. hourly, per session, barter, and what amount is your usual fee quoted to potential clients?

All practitioners credentialed by the ASHMP need to carry professional liability insurance. (If you do not yet have insurance, you may instantly purchase a year's coverage for $25 via this link.) Please upload proof of coverage here.

What continuing education, courses, or books have you added to your learning and growth in the past year?

In what ways does your practice uphold the ASHMP Standards? In other words, why should we consider your practice for approval? What would you like us to know about your practice that shows that it represents the best of this work?

Step 2: Click the button below to submit the application fee ($197 $155 through 2014)