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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.
Please note that our arrangement with Balens Ltd., for Block Scheme Professional Indemnity Insurance applies to UK residents only.