Surname ........................................................

First Name .....................................................

Date of Birth ...................................................

Tel. (home) ....................................................

Tel. (work) .....................................................

Tel. (mobile) ...................................................

Male / Female

Title Mr. / Mrs. / Ms

E-mail Address ................................................

Address for correspondence

................................................

................................................

................................................

................................................

Post Code...................................

London Course

Brief educational history and qualifications awarded

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

Are you in any form of study at present? If so, can you say what it is and when you expect to finish

................................................................................................................................

................................................................................................................................

................................................................................................................................

 

Employment / work experience:

Present job

..........................................................................................

..........................................................................................

Date appointed

................................................

List any previous jobs, or training which you think might be relevant to this course

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

List membership of societies or professional associations, if any, to which you belong:

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

Have you been in counselling, psychotherapy or hypnotherapy?
If so please give brief details

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

Are you taking any form of medication? If so please list below

..........................................................

..........................................................

..........................................................

Please state why you wish to study Psychotherapy & Hypnotherapy (continue overleaf if necessary)

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

Please give the name and address of a referee who can attest to your suitability for the proposed course.

Name...................................................

Address................................................

..........................................................

..........................................................

......................Post Code.......................

Where did you hear about this course?

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................