AHHA PRACTITIONER MEMBERSHIP APPLICATION


You can use the application form on this page to fill out and submit the application online
OR
You can download and printout an application form to fill out and mail in.

APPLICANT'S NAME:
Full Name:
Gender:

APPLICANT'S CONFIDENTIAL CONTACT INFORMATION - for use by AHHA only:
This information is kept confidential, unless authorized elsewhere for inclusion in listing.
Name of Business:
Work Phone:
Home Phone:
Cell Phone:
Email:
MAIL TO ADDRESS:
Street Address:
City:
State:
Zipcode:
Country:

MEMBER LOGIN:
Each AHHA membership has a login/password for access to the online AHHA Members Only Section. Designate an email that can be used in case you forget your password in the future. It is best to use a personal email.
Login-related email to use:

AHHA's GO GREEN options:
AHHA strives to go green and minimize our paper consumption
Thank You Packet materials and bi-monthly member newsletter issues are accessed online in the Members Only Section
While we are happy to mail you specific materials, we ask you to verify what you wish to receive by mail...
Receipt
Certificate
Booklets

If your Mail To address is outside of the U.S., you need to prepay mailing costs of any materials sent to you.

APPLICANT'S QUALIFYING CRITERIA:
To qualify for AHHA Practitioner Membership an applicant must have FULLY COMPLETED formal training for at least one healing modality and have authorization to practice (including any locally required license). In-progress training does not count until completed. Self study, self-developed programs, organizational memberships, and career positions are not considered formal training. Note that a certificate of completion is not professional certification. Training information provided is kept in the AHHA office computer and shared with the public, on request.

For any healing modality you wish mentioned in your listing, the following information must be provided: List each separately.

1) Full Name of Course, Degree, Certification, License SEPARATE WITH /
2) Full Name of School or Organization (with website) SEPARATE WITH /
3) Year Completed (add month if current year) END WITH ;


MEMBER'S AUTHORIZED DATA FOR PUBLIC LISTING - shared with the general public:
The following information is authorized to be in the AHHA Practitioner Member's listing shared with the general public in print and online.
First Name:
(If needed you may include middle name or initial)
Last Name: (searchable field)
(searchable field)
Initials after name:
(For degrees, trainings, certifications, licenses, no memberships. Be sure documented in the APPLICANT'S QUALIFYING CRITERIA section above)
Name of Business:
(Use if practice has a legal company name)
City: (searchable field)
(searchable field)
State: (searchable field)
(searchable field)
Zipcode: (searchable field)
(searchable field)
Country: (searchable field)
(searchable field)
Website search system can only handle one address. If practice has more than one office, a second office may be mentioned in descriptive text of listing.
Phone:
Email:
Website:
(Listing hyperlink limited to one website)
Descriptive text you are authorizing to be in your listing:
Space limits restrict the following three fields to a cumulative total of about 65 words or 490 characters (dictated by printed version of list). Note: Each modality mentioned here must be documented in the APPLICANT'S QUALIFYING CRITERIA section above.

1) Type of healthcare professional While you may offer many modalities, pick most important ONE. [Examples: Hypnotherapist, Medical Doctor, Wellness Coach] Note: AHHA policy is to use “doctor” designation only for identifying licensed physician-level trained healthcare professionals.

2) Healing modalities offered Your opportunity to identify what you provide your patients/clients. Unless you are a licensed physician-level trained professional authorized to diagnose and treat, recommend not using terms such as medical, medicine, healing, therapy, treat, or treatment.

3) Key training Your opportunity to identify your most important/impressive professional training. Select from what you listed in APPLICANT'S QUALIFYING CRITERIA section of this application, and enter below in prority order. Only need to include the name of degree, course, certification or license plus name of the related institution.

MEMBERSHIP REQUEST:

Yes, I work in partnership with my patients/clients and encourage a holistic approach to wellness, which encourages individuals to:

  • Make lifestyle choices that promote wellness
  • Participate actively in their health decisions and healing processes
  • Balance and integrate their physical, mental, emotional and spiritual aspects
  • Establish healthy and respectful relationships with others and the world around them.

Yes, I grant permission for release of the authorized information for the AHHA Practitioner Member networking list and other public relations opportunities.

Yes, I want to become a Practitioner Member of the AMERICAN HOLISTIC HEALTH ASSOCIATION and certify that the information I have presented above is accurate.

NOTE: For a legal equivalent of your signature in response to the above questions you must enter your full name and today's date in the Signature box below.
SIGNATURE: * (enter your full name and today's date)


MESSAGE TO AHHA:
This area is provided to offer you an opportunity to send a special message to AHHA.

CONTRIBUTION INFORMATION:
AHHA is a designated 501(C)(3) - Tax ID# 33-041271
Contributions are tax deductible as allowed by law


BASIC
$60

FOREIGN POSTAGE
$



EXTRA
$













TOTAL
$


BASIC AHHA MEMBERSHIP CONTRIBUTION
AHHA Practitioner Membership contribution for the next 12 months


For non-U.S. addresses - add mailing costs for any requested mailed materials


ADDITIONAL DONATION
Contributing an additional amount to expand the outreach of this valuable organization
Over and above the basic contribution above, I donate an additional donation amount
Platinum Circle = $500 or more
Gold Circle = $250 - $499
Silver Circle = $100 - $249
Bronze Circle = $50 - $99
Extra Gift = $49 or less

With permission of the donor, an extra donation over and above the basic membership contribution amount is acknowledged in the Honored Donors section of our website at ahha.org/honored-donors with the name of the donor. Gold and Platinum Circle level donors can add a hyperlink.
I grant permission to be added to the Honored Donors list

COMBINED SUPPORT TO AHHA
Type in the TOTAL AMOUNT you intend to contribute to AHHA.
This is the SUM of basic membership contribution, plus mailing costs (if requested materials mailed to non-U.S. address), plus any additional donation you would like to make.

Print out a copy of all of the above for your records, as back up in case of a technical glitch in information transfer.

SUBMIT APPLICATION INFORMATION TO AHHA:
After you click on SUBMIT button below, the data you entered above will be emailed to AHHA.
AND you will be transferred to the payment information screen.
Pick Option #1 to indicate you plan to mail a check or money order to AHHA to make your membership contribution.
Pick Option #2 to indicate you plan to use your credit card to make your membership contribution.
Method will use to make membership contribution