European College of Hypnotherapy

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

Booking Form


BOOKING FORM  – Hypnotherapy Training

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_____________