tAmerican Holistic Health Association (AHHA) - Practitioner Membership Application Form

AHHA PRACTITIONER MEMBERSHIP APPLICATION


You can use the online renewal form on this page to fill out and submit AND then access Authorize.net or PayPal for an online credit card transaction OR then mail a check or money order to AHHA.
OR
You can download and printout an application form to fill out and mail with check or money order to AHHA.

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 (REQUIRED):
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 IS PAPERLESS
Your AHHA membership contribution receipt is emailed to you.
Your AHHA membership certificated is emailed to you.
The bi-monthly member newsletter issues are accessed online in the password-protected Members Only Section.

PROFESSIONAL QUALIFICATIONS:
You may be qualified for many healing modalities, but AHHA only needs the following for those you wish to mention or reference in your AHHA Practitioner Member listing.

PLEASE REVIEW THE FOLLOWING CAREFULLY
* Submit only formal trainings that you have successfully FULLY COMPLETED. In-progress trainings will not be mentioned in your listing.
* Self-study, self-developed programs, organizational memberships, and career positions are not considered formal trainings, and will not be mentioned in your listing.
* While doctorate degrees can be mentioned in the Key Training portion of a listing, physician or doctor designation in a listing requires a government issued license granting authorization to diagnose and treat.

Information submitted is kept in the AHHA office computer and any data there is no room to mention in a public listing will be shared on request.

HOW TO PROVIDE REQUIRED DATA for each healing modality you wish mentioned or referenced in your listing:

For each modality TRAINING include all of the following data in ONE BOX BELOW...
1) Full Name of a Training Degree or Course, as it appears on the diploma or certificate of completion
2) Full Name of the School or educational organization, as it appears on the diploma or certificate of completion
3) Website URL for school mentioning this specific training [if not available - scan & email copy of diploma or certificate of completion]
4) Date of graduation/successful completion of training, as it appears on the diploma or certificate of completion
5) If not obvious - brief explanation of healing modalities the training prepared you to use with your patients/clients
6) Mention if this training school also provided certification. Note: a certificate of completion is not "certification."

For each modality CERTIFICATION provided by an organization separate from the training school include all of the following data in ONE BOX BELOW...
1) Full Name of a modality Certification, as it appears on the certificate
2) Full Name of awarding Organization, as it appears on the certificate
3) Website URL for awarding organization mentioning this specific certification [if not available - scan & email copy of certification certificate]
4) Date of certification, as it appears on the certificate
5) If not obvious - brief explanation of healing modality the certification covers

For each modality LICENSE include all of the following data in ONE BOX BELOW...
1) Full Name of the License, as it appears on the license
2) Full Name of issuing Government Entity, as it appears on the license
3) License number
4) Website URL for the government entity where one can verify a specific license [if not available - scan & email copy of license]
5) License expiration date, as it appears on the license
6) If not obvious - brief explanation of what the license authorizes

Reminder: For submitting Trainings, Certifications and Licenses enter the complete data for each one in a separate box below.

#1:
#2:
#3:
#4:
#5:
#6:
#7:
IF MORE THAN 7 ITEMS, add any additional training, license or certification data here:
MEMBER'S AUTHORIZED DATA FOR PUBLIC LISTING - shared with the general public:
This section of the application is where you authorize what AHHA can share with the general public. WE WILL NOT FILL IN FROM WHAT YOU POSTED PRIOR ON THIS APPLICATION.Only what you fill in here can be included in your AHHA Practitioner Member listing.
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 PROFESSIONAL QUALIFICATIONS 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 be a cumulative total of about 65 words or 490 characters (dictated by printed version of list).

1) Type of health care professional While you may offer many modalities, pick most important ONE. [Examples: Medical Doctor, Naturopathic Physician, Massage Therapist, Holistic Health Practitioner, Wellness Coach]. Note: AHHA policy is to use doctor or physician designation only for identifying licensed physician-level trained health care professional authorized to diagnose and treat.

2) Healing modalities offered Your opportunity to identify what services you PERSONALLY 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 DOCUMENT APPLICANT'S QUALIFYING CRITERIA section of this application, and enter below in PRIORITY ORDER. Must include the name of degree, course, license or certification AND name of the related institution. Reminder that if you are identifying as doctor or physician, you must provide license information. Separate each item with ;

Note: Each healing modality mentioned anywhere in your listing must be fully documented in the PROFESSIONAL QUALIFICATIONS section above OR YOUR APPLICATION WILL BE ON HOLD UNTIL MISSING DATA IS PROVIDED.

New Benefit as of January 2021: List the options you use to interact with your clients. in-person, phone and/or virtual. Those you type in below will be added into the descriptive text of your listing. In lockdown situations this can be helpful to let prospective clients know.

MEMBERSHIP REQUEST:

Yes, I encourage a holistic approach to wellness where individuals:

  • Balance and integrate themselves physically, mentally, emotionally, and spiritually
  • Establish healthy and respectful relationships with others and the world around them
  • Make lifestyle choices that promote their wellness
  • Participate actively in their own health decisions and healing process.

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 field below.
MANDATORY 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


EXTRA
$


















TOTAL
$


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


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
Copper Circle = $5 - $49

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 any additional donation you would like to make.

We strongly recommend that you 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:

IMPORTANT: THIS FORM DOES NOT MAKE YOUR PAYMENT.
BELOW YOU INDICATE WHICH OPTION YOU WILL USE TO MAKE YOUR CONTRIBUTION.
 Select one from the following menu:
Pick Option #1 to indicate you plan to use your credit card to make your membership contribution.
Pick Option #2 to indicate you plan to mail a check or money order to AHHA to make your membership contribution.
Method will use to make membership contribution

Now click on SUBMIT button below so that the data you entered above is emailed to AHHA.
After you hit the SUBMIT button, you will be transferred to a new page with links to secure payment options by credit card.