PHPA Application Form

Please print this form before completing your payment.  It may be scanned and emailed to PHPA Sales or posted to:

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

We require supporting evidence of your qualification in hypnotherapy which can be sent as a scanned copy by email attachment or posted to the above address.  Applications will be approved upon confirmation by the relevant training establishment.  In the event that confirmation is not forthcoming then any payments will be refunded in full.

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: