Hypnotherapy Training
Enrolment
(NB: The GHSC accredit both Foundation and Practitioner level training, other accreditation is for Practitioner level only)
01977 678593
Correspondence address: Keldale House, Beal Lane, Beal Yorkshire DN14 0SQ
(Training at venues throughout Yorkshire)
OFFICE USE ONLY - REF NO:
Please complete all questions and either type or write your answers in BLOCK CAPITALS.If you run out of space for any question, or have questions or comments that don’t fit onto the form, please go onto a separate piece of paper.You may be asked to have an interview before being considered for a place on this course. This is often done by phone.
Queries? Tel 01977 678593 or email
Send the completed form to Debbie Waller, Keldale House, Beal Lane, Beal, N Yorkshire, DN14 0SQ.
Email submissions are also accepted. All information on this form will be treated as confidential.
Name as you would like it to appear on your certificates:
What do you like to be called?
Address:
Telephone number:
Email address:
A. Your Learning Preferences
Please note that the variations offered depend upon student numbers, and cannot be guaranteed.
A1. Course: Foundation Level only (4 modules) Practitioner Level (10 modules)
A2. Preferred format: (start dates for each option are on the website)
(Indicate order of preference by entering 1, 2, 3 leaving blank any you would not be able to attend.)
Wakefield weekends (Spring start) York weekends (Autumn start)
Term time weekdays (Spring start)
If you have chosen term time weekdays, please give the following additional information.
Classes will be arranged to be accessible to as many students as possible based on your address and what you put here.
Which days could you attend? Mon Tues Wed Thurs Fri
Will you be relying on public transport? Yes No
A.3. How did you first become aware of this course?
(Please be as specific as you can eg Google search, Google ads, Facebook, etc rather than Internet.)
A4. If accepted, how would you prefer to pay for the course?
(This will not have any influence on whether you are offered a place, but it helps us invoice you correctly)
Deposit followed by monthly instalments
Deposit then balance by module one
(5% discount, practitioner level students only)
Not sure yet
B. Data Protection and other formalities
Please read before submitting this form. This tells you how I collect, look after and use your personal data.
Under the GDPR, you need to agree to each separate use of your data. You can withdraw permission for any of these uses at any time by letting YHT know in writing. In the case of the newsletter you can unsubscribe using the link on each email.
B1. Tick to confirm that you have read our privacy policy, and agree to use using your personal data in the ways specified, specifically:
(Please tick each box to indicate consent)
to answer queries and provide you with support
to enable YHT to decide if we can offer you a place on one of our courses
to administer the course once you are enrolled
to enable me to invoice you and receive payment, and to keep proper records and accounts
to sign you up for the YHT monthly newsletter
- You understand that if you are offered a place on this course it will be on the basis of the information you are supplying on this form and
- You affirm that this information is true and complete.
- You understand that format, date and venue choices are offered on a provisional basis only and that actual classes run will be dependent on student numbers.
Signed:
Print name:Date:
OFFICE USE ONLY - REF NO:
C. Your Background and Medical History
These questions are relevant to your ability to practice as a therapist, and/or to enable you to be hypnotised safely in classroom exercises. A ‘yes’ answer does not necessarily prevent you from taking the course, and your answers will be kept confidential. If you have any queries about how these issues might affect your enrolment, please feel free to contact us.
C1. Do you have any unspent convictions under the
Rehabilitation of Offenders Act 1974?Yes No
C2. Do you take any regular/long term medication? Yes No
C3. In the last 3 years, have you undertaken any kindYes No
of psychotherapy, hypnotherapy or counselling?
C4. Have you ever suffered from any of the following?
Addictions (other than smoking)Yes No
Eating DisordersYes No
EpilepsyYes No
Insulin Controlled DiabetesYes No
Personality DisorderYes No
PsychosisYes No
Other long term/on-going health problem? Yes No
C5. Have you any special needs e.g. regarding access?Yes No
C6.If you have answered yes to any of the above, please give details:
OFFICE USE ONLY - REF NO:
D. About You
D1. Are you over 21? Yes No
D2. Have you attended a YHT taster day?Yes No
D3. Do you have any other experience of hypnotherapy?Yes No
If yes please explain briefly
D4. Are you trained in any other kind of therapy? Yes No
If yes please explain briefly
D5Why do you think you should be offered a place on this course?
This is your chance to tell us about yourself, e.g. why you want to come on this course, what skills, interests or experience do you have that might be useful, where does your interest in hypnotherapy come from, what do you hope to get from the course?Continue on another sheet if you need more space.