PHPA Application Form

Full name

E-mail address

Web-site address (including full URL)

Postal address (including State/County, zip/postal code & country)

Telephone Number (including area code)

Appointment Phone No.:

The public phone number for clients to call for appointments

Professional Information (as you wish it to appear on your membership certificate)

Professional Name and/or Business Name:

Year began using hypnotherapy:

How extensively do you use hypnotherapy?:
-- Full Time Part Time As an adjuct to primary profession

Education, background, seminars, etc.:

In what areas do you use hypnosis:
-- Smoking Cessation Clinical social work Marriage & family therapy Medicine / healing arts Sports Performance Clergy / Pastoral counseling Forensic / Law enforcement Weight Control Phobias / Fears Psychotherapy Counseling Dentistry Chronic Pain Learning Skills Stress / Anxiety Other

Memberships, Certifications, licenses, etc.:

Specialty:

Please print this form before completing your payment.  It may be scanned and emailed to Sales@phpa-online.org or posted to:

PHPA, 24 St David's Drive, Scawsby, Doncaster, Yorkshire, DN5 8NF, England.