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Contact Us Membership Application Form "*" indicates required fields Type of MembershipSelect Type of Membership* Student Membership Associate Membership Corporate Membership Social Welfare Membership Volunteer Membership Personal InformationFull Name per IC* Mr.Ms.Mrs.Dr.Prof. Dr.DatoDatinDato SriDatin Sri Prefix First Nickname / Shortname* IC / ID No.* Nationality*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte 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Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone Number*Email* Address* Street Address Address Line 2 City State / Province / Region Postcode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Qualification InformationHypnotherapy / Psychotherapy Qualification StudiesClick + to add moreDate of Graduation (dd/mm/yyyy)Name of Institution / AcademyName of Program / Course Add RemoveNational / International Accreditation BodyClick + to add moreDate of Accreditation (dd/mm/yyyy)Name of Accreditation Body / AssociationName of Professional Title Add RemoveAcademic QualificationClick + to add moreYear of GraduationName of College / UniversityMajor Studies Add RemoveOther Professional Program Attended (If Any)Click + to add moreCourse NameDurationName of Institution / AcademyProfession Add RemoveKindly select your modality in mental health industry.Select one or more Hypnotherapy Psychotherapy Counselling Psychology Art Therapy Child Therapy Speech Therapy Cognitive Behavioural Therapy Other Other Modality Document ChecklistKindly upload your documents for verification purpose.IC / National ID Copy (Front and Back)* Drop files here or Select files Max. file size: 50 MB. Passport Size Photo / Formal Photo Drop files here or Select files Max. file size: 50 MB. Highest Education Qualification and CertificationSPM, Diploma, Degree, Master or Phd Drop files here or Select files Max. file size: 50 MB. Letter of Admission / Offer Letter Drop files here or Select files Max. file size: 50 MB. National or International Certificate in field of Mental HealthHypnotherapy, Psychotherapy, Psychology or other relevant certification Drop files here or Select files Max. file size: 50 MB. Company SSM Superform Drop files here or Select files Max. file size: 50 MB. Membership Fee DetailsMembership Fee shown as annual fee.One-Time Registration Fee Price: Student Membership Price: Associate Membership Price: Corporate Membership Price: Social Welfare Membership Price: Volunteer Membership Price: Coupon Code (If Any) Total Fee Membership AgreementAgreement*- I hereby confirmed and agreed that all information that I provided are absolutely accurate and correct. - As being as MIHA members, I also agreed to comply with included but not limited to MIHA's Code of Ethic, Code of Discipline, Guidelines, Policies and Membership Handbook. Yes, I Agree.Signature*Full Name per IC* PhoneThis field is for validation purposes and should be left unchanged.
