The Hoffman Process
Bursary Application Form
From time to time we are in a position to offer a limited number of partial Bursaries. Financial support is available to those who otherwise could not afford the full fee. We particularly consider those who have professionally dedicated themselves to serving others, such as charity workers, social workers, and for people whose work in their communities would benefit from the Process.
Criteria for receiving a Bursary include one's readiness to take advantage of the Process, the level of responsibility one exhibits in both personal relationships and finances and, finally, the potential contribution that the Process could make to the life of your family, the people you serve and your community. All those applying for Bursaries must demonstrate financial need providing supporting evidence, your application will not be considered without.
Please complete the form providing answers for each section. This form, with copies of payslips/tax returns etc, should be returned to the Bursary Committee at Hoffman Institute UK Ltd., PO Box 72, Quay House, Arundel, West Sussex, BN18 9DF or emailed to . The information you submit is completely confidential.
Contact and personal details
Name: Date of Birth: National Insurance Number:
Address:
Home Tel: Work Tel:
Mobile: email address:
Please click the box(es) next to the number(s) you would prefer us to use to contact you.
Are you Retired/Employed/Self Employed/Unemployed/Student:
Marital Status: Number of children/dependants:
How/from whom did you first learn about the Hoffman Process? (Please specify name)
In Support Of Your Application
Why do you feel the Hoffman Process is appropriate to you at this time?
If you have been in therapy or had counselling please provide details
Are there any other biographical details that you feel could help your application?
Financial Position
Household Income:
From employment, indicating gross and net pay, details of bonuses or commissions and attaching copies of last P60 and last 3 months pay slips (please do not send originals as we cannot guarantee their safe return).
If self employed, copies of your most recent set of accounts
Income from State benefits, specifying type of benefit and amount
Savings, please Savings, please specify type of savings, amount and interest earned earned
Income from any other source, e.g. Partner/Spouse, Tenants/Lodgers, Bank interest, specifying source and approximate amount and whether gross or net
Outgoings: State whether Annual (pa) Monthly (PM) Quarterly (PQ) or WEEKLY (PW)
ACCOMMODATION / TRANSPORTMortgage/rent / £ / Car Loan / £
Gas/Solid fuel/Oil / £ / Petrol/Deisel / £
Electricity / £ / Road Tax / £
Water Rates / £ / Insurance / £
Council Tax / £ / Car Repairs / £
Telephone/Internet / £ / Breakdown Insurance / £
HOUSEHOLD COSTS / Public Transport / £
Food and Housekeeping / £ / LOANS AND CREDIT
Buildings and Contents Insurance / £ / Credit cards / £
Meals out/takeaways / £ / Store card repayments / £
Television licence/Sky etc / £ / Hire-Purchase / £
PERSONAL EXPENSES / Bank Loan / £
Pension payments / £ / Other Credit / £
Shoes and Clothing / £ / CHILDREN
Dry Cleaning / £ / Child minder’s fees / £
Leisure and holidays / £ / School/Preschool/Creche fees / £
Hairdresser / £ / Nanny/Au Pair / £
Dentist / £ / School Dinners / £
Optician / £ / Uniforms / £
Prescriptions / £ / Outings and trips / £
Therapy/Counselling / £ / Other school expenses / £
Birthdays and Christmas / £ / Private lessons / £
Fines / £ / Children’s activities / £
Gym/Health Club Membership / £ / Toys and books / £
Health Insurance / £ / Children’s pocket money / £
Maintenance payments / £ / OTHER EXPENDITURE
Newspapers/magazines/subscriptions / £ / £
Mobile Phone / £ / £
The Hoffman Process Enrolment Form
Please return this form immediately – Your place is not secured until we approve this application
I am enrolled in the following Hoffman Process date:
Name: Date of Birth: Gender: Nationality:
Occupation: Company/Position:
Address:
Home Tel: Mobile No:
Please check the box next to the number you would prefer us to use to contact you.
Email: Skype:
How/from whom did you first learn about the Hoffman Process? (Please specify name)
You have registered for the Hoffman Process to be held at one of our Hoffman venues. Registration is on Saturday between 9 and 9.30am, the course finishes at 2pm the following Friday. If you would like to arrive earlier, it is possible to stay the night before.
I wish to stay at the chosen venue on the Friday night before the course
(Bed & Breakfast incurs additional charge. Please arrive between 4pm & 10pm, if you are delayed or going to arrive after 10pm, please call the venue. If your booking is no longer required, please cancel to avoid incurring a charge).
I would like dinner on Friday (Served at 7pm, £17.50) I do not require dinner
I will arrive at the venue on Saturday morning (Registration is between 9 and 9.30am)
Are you Vegetarian? Yes No Do you eat fish? Yes No Do you snore? Yes No
Do you eat pork? Yes No
All Hoffman venues provide nutritious and wholesome food for the week of the Process. We do not recommend that you use the week to detox or change your diet. The work is challenging and physical so it is important that your body receives the essential nutrients it needs to do this work. If you have medical dietary requirements, they will cater for the following diets by special arrangement, at an extra charge - details of this charge will be given upon confirmation of your Process.
Vegan Gluten free Wheat free Dairy free Lactose free
Other – please specify:
Payments for Friday night, Friday dinner and special diets to be made directly to the venue before arrival, you will be given venue details once your place is confirmed.
EMERGENCY CONTACT DETAILS
In case of a natural or man-made disaster and/or national crisis either in the UK or your home country, we may need to make contact with at least one person who knows you are on the Process. Please indicate which person/s below know you are on the Hoffman Process (tick box).
In case of a personal emergency we will contact either person listed below.
Name Relationship Daytime Tel Evening Tel
Name Relationship Daytime Tel Evening Tel
YOUR APPLICATION TO PARTICIPATE IN THE HOFFMAN PROCESS:
Your application is confidential and it must be approved by the Hoffman Institute before you can attend the Hoffman Process. We also require you to read the Terms and Conditions (found with your registration documents) as they contain information about cancellation policies.
We realise that the questions on this form may bring up sensitive issues, and your answers will help us to assess whether there is any reason why you should not participate in the Process. Of course it is not possible for us to predict any participant’s experience, or the effect of the Process on them, but if we feel that for any reason it is not appropriate for you to attend, we will try to recommend an alternative course or treatment. Your deposit will be refunded to you at this point.
Once your application is approved, the deposit you have paid becomes non refundable and non transferable. Please ensure that you have read and fully understand and agree to our Terms & Conditions.
Please note that you are required to sign the Declaration & Consent Agreement prior to attending the course.
In some cases, as indicated later in this form, we may require that you contact a Doctor or Therapist before you participate in the Process. It is a condition of your participation that you notify us before starting the course if there is any change to the information you have provided.
Your submission of this form means you understand and agree to be legally bound by these terms
and also agree that the information given is accurate.
If you have any questions please contact the office on: 01903 88 99 90 or email:
Physical Health
If the answer to the following questions 1-20 is ‘Yes’, please give an explanation after question 20, including month and year.
Has a doctor or other practitioner ever treated you for or told you that you had: Yes No
1. Tumour, Cancer, or other growth
2. Shortness of breath, chest pain, stroke, rheumatic fever, heart trouble or murmur, high blood pressure, or asthma
3. Indigestion, colitis, ulcer or disorder of stomach, intestines, bowel, or rectum
4. Gallbladder disease, kidney disorder or stones, liver trouble
5. Epilepsy, dizzy spells, convulsions, loss of consciousness, or paralysis
6. Brain concussion
7. Have you ever been diagnosed as having severe or frequent headaches?
8. Diabetes or sugar in the urine
9. Pus, blood, or albumin in the urine, disease of kidney or urinary tract
10. Rheumatic fever, arthritis, joint or muscular disorder
11. Allergies
12. Reading or learning disability
13. Have you ever been refused insurance on medical grounds?
14. Are you suffering from any infectious disease?
15. Have you ever had any injury, disease, condition, surgery, or other disorder other than the above?
16. Do you have any reason to believe that you are not in good health?
17. This course involves vigorous bodily movement and physical stress. Do you have any physical limitations which might affect your ability to participate?
18. Have you any physical problems that could be aggravated by emotional stress
19. How many hours of sleep do you normally get?
Yes No
20. (Women only) Are you pregnant?
If ‘Yes’ how many weeks are you now?
If you are pregnant we would require you to consult with your doctor and contact the office before we accept you on the Hoffman Process. Please note that if you become pregnant between completing this application and attending the course, you must consult your doctor about attending and confirm this with us.
Explanations to Questions 1-20 if the answer is ‘Yes”
21. Are you taking any prescribed medication for any disorders you have mentioned?
If ‘yes’, Please specify which one and for how long:
22. Do you drink alcohol?
If ‘yes’, how much and how often do you drink?
23. Do you use recreational drugs?
If ‘yes’, what drugs and how often do you take them?
Please note: In order to gain the most from the course, we ask that you refrain from alcohol and any substances which may affect your concentration or ability to access your feelings, for at least one week before the course starts and throughout the duration of the course. For your own safety and the safety of others it is a requirement of the Hoffman Institute that you do not bring or consume alcohol or recreational drugs at the Process venue. If you breach or break this agreement you will be asked to leave the Process and premises.
24. Do you have, or have you ever had an eating disorder?
If ‘yes’ please give details and dates:
25. Are you in Recovery for any of the above?
If ‘yes’, please explain which and how long you have been in Recovery.
Based on the answers you have provided, we may recommend that you participate in therapy or spend longer in recovery before attending this course
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What would you say is the main reason you want to do the Hoffman Process?
What would you say are your current main sources of stress? For example, current relationship/family problems, separation, divorce, work stress, illness, bereavement, addictions, major life changes
Please provide the name of your Doctor in case of emergency:
Name: Phone Number:
Address:
Email:
We have guidelines about the Hoffman Process that we send out to health professionals. Would you like us to send some to your doctor? Yes please No thank you
Therapy
Name: Phone Number:
Address:
Email:
It is standard practice for the Institute to send Professional Guidelines and a Research pack to any therapist whom you are seeing, so that they can give you an informed viewpoint as to the suitability of the course for you at this time. The information will also help your therapist support you before and after the Process.
Please tick this box if you would NOT like us to send Guidelines to your Therapist
(We only send the Guidelines to your therapist directly – not via a third party).
Yes No
1. Are you currently in therapy? (If ‘No’ please go to Question 2)
When did you start going and what type of therapy is it?
How often do you see your therapist?
What issues are you seeing your therapist for and how are you benefiting?
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2. Have you been in therapy in the past? (If ‘No’ please go to Question 3)
When and how often did you go?
What kind of therapy was it?
What issues were you seeing your therapist for and how did you benefit?