European College of Hypnotherapy

European College of Hypnotherapy, UK
UK Tel: 01784 433421    •    International Tel: 0044 1784 433421

Booking Form


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BOOKING FORM  – Hypnotherapy Training                                                                                           

I SHOULD LIKE TO ENROLL ON THE FOLLOWING COURSE:  (Please TICK). 

□    EXPRESS COURSE – DIPLOMA IN HYPNOTHERAPY   Starting:……………………….

□    6-WEEKENDS COURSE – DIPLOMA IN HYPNOTHERAPY  Starting:………………………

 □    CERTIFICATE IN PAST-LIFE THERAPY & SPIRIT-RELEASE THERAPY  Starting: …………….

□    ADVANCED DIPLOMA IN HYPNOTHERAPY Starting:………………………………….

Please print, complete, and send with non-returnable deposit – payable to Dr Keith Hearner, E.C.H. OFFICE,               5, Schroder Ct, Northcroft Rd, Egham, Surrey, TW20 0EH.                                                                                        (Ring 01784 433 421, or email us via Contact on our website, if you have any queries)

CONFIDENTIAL INFORMATION

Name___________________________________________________________________

Address_________________________________________________________________

_____________________________________________________Post code___________

Email address___________________________________________________________

Occupation_______________________ Qualifications____________________________

CONFIDENTIAL DECLARATION             Continue answers overleaf if necessary.

1.Have you ever been convicted of a criminal offence? YES/NO       If so, give info overleaf.

2.Please state any serious psychological illness that you have experienced  If so, give info overleaf.

3.Do you currently have any serious psychological disorder(s)?  YES/NO If so, give info overleaf.

4.Are you taking any medications? YES/NO      If so, give info overleaf.

5.Have you ever been the subject of professional disciplinary proceedings? YES / NO  If so, give info overleaf.

Should any of these situations arise during my training I will inform the College immediately.

Signed ____________________________________________ Date_____________