Hypnotherapy Institutes
Registration Application Form
Email
hypnotherapyinsitute@comcast.net
509-327-4465

Name______________________________________  Social Security#____________________

Address_________________________________________ Birth Date ___________ Age_____

City___________State____ Zip_________  Phone Hm._____________  Work_____________

Email_____________________Employer__________________Position____________

In Case of Emergency Call ________________ Phone__________________________

Highest Level of Education: GED ___ HS ___ MA/MS__ PhD __Other______________

How did you hear about this school? ______________________________________________________________________

Any experience with hypnotherapy? ______________________________________________________________________

What do you plan to accomplish/experience by taking our training? ______________________________________________________________________

______________________________________________________________________
Do you have any special physical needs we should know about? ______________________________________________________________________

______________________________________________________________________
Have you ever been diagnosed with a mental illness? ______________________________________________________________________

Are you currently on any antidepressant, anti psychotic, or other mood altering medications? Y/N

Are you currently misusing alcohol or drugs?_____________________________________________________________________

Do you have any felony or morals convictions or charges in your background?_____________________________________________________________________

I understand that the Hypnotherapy Institute of Spokane offers no placement services or guarantee of employment to the graduates of this course. I understand the intense and emotionally based nature of this training may stimulate me to deepen my personal growth. I commit an oath of confidentiality of the personal information I am witness to during this trainingI take full responsibility for my health and well-being during class hours.

Registration Fee of $100 must accompany registration form. This deposit is non-refundable after registration is accepted, unless classes are canceled.

Signature_______________________________      Date_________