Booking Form
I SHOULD LIKE TO ENROL ON THE FOLLOWING COURSE: (Please TICK).
□ EXPRESS COURSE – DIPLOMA IN HYPNOTHERAPY Starting:……………………….
□ 6-WEEKENDS COURSE – DIPLOMA IN HYPNOTHERAPY Starting:………………………
□ CERTIF. IN PAST-LIFE THERAPY & SPIRIT-RELEASE THERAPY Starting: …………….
□ ADVANCED DIPLOMA IN HYPNOTHERAPY Starting:………………………………….
Please print, complete, and send with non-returnable deposit of £500 – payable to:
Dr Keith Hearne.
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___________________________________________________________
Tel:________________________________
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_____________