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
  • Your membership contribution receipt is emailed to you
  • 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...
  • To receive certificate by mail you must check the following box
               Yes, mail member certificate
  • To receive your five booklets by mail you must check the following box
               Yes, mail 5 copies of booklet Wellness From Within: The First Step

    Is your Mail To address outside of the U.S.? Then 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 completed formal training for at least one healing modality and have authorization to practice (such as any locally required license), if needed. Note that a certificate of completion is not professional certification. In-progress training does not count until completed. Self study, self-developed programs, organizational memberships, and career positions are not considered formal training. The information provided is kept in the AHHA office computer and is shared with the public, on request. For each modality training, license, and certification mentioned in your listing, the following must be provided:
    Name/Type Training                        Training Institution or Individual                        Year Completed (add month if current year)


    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:
    (May include middle name/initial)
    Last Name: (searchable field)
    Initials after name:
    (For educational/professional degrees and certifications, using periods or no periods)
    Name of Business:
    (Use if practice has a legal company name)
    City: (searchable field)
    State: (searchable field)
    Zipcode: (searchable field)
    Country: (searchable field)
    (The search system can only handle one address. If practice has more than one office, second office may be mentioned in descriptive text of listing.)
    Phone: (searchable field on area code)
    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 - to identify your status list predominant modality, such as Hypnotherapist, Medical Doctor or Wellness Coach. Note: AHHA policy is to not use "doctor" in identifying type of healthcare professional, unless licensed physician-level trained professionals.

    2) Healing modalities offered - to identify what patients/clients can expect. Unless a licensed physician-level trained professional authorized to diagnose and treat serious illnesses, recommend not using terms such as medical, medicine, healing, therapy, treat, or treatment.

    3) Key training - to identify most important/impressive professional training. Yes, this is repeating some (or all) of the training data you shared in APPLICANT'S QUALIFYING CRITERIA section of this application, but here is where you authorize that can appear in your listing.

    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/donors.asp 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:

    Method will use to make membership contribution
    After you click on SUBMIT button, you are transferred to the payment information screen.
    Option #1 is to mail a check or money order to AHHA.
    Option #2 is to use your Visa, MasterCard, or DiscoverCard. For this there will be a button to transfer you to the Authorize.net secure website. Once there you enter the amount you are donating, then transfer to a form on the Authorize.net secure server where you enter your confidential credit card information.