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Mr Mrs Miss    Forename: *   Surname: *

Address: *

Address:

Town/City:

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Country : Ireland UK Other *

Tel (Home): *

Tel (Work):



Email Address: *

Date of Birth: *

Marital Status:

Occupation: *

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On the line below, print clearly the form of your name as you would like to see in on any Certificates or Awards

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Qualifications, Diplomas, etc received:

     
     
     

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How did you hear about this course?

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Please read each of the following and indicate the level of relevancy it has to you.
0: Not relevant     2: Medium relevancy     4: A Priority

Are you interested in studying hypnotherapy / psychotherapy because you want to:

Find a new career, full-time or part-time.	0 1 2 3 4
Be your own boss.	0 1 2 3 4
Acquire advanced training if required.	0 1 2 3 4
Become a certified, registered hypnotherapist.	0 1 2 3 4
Acquire the necessary skills to help your fellow man.	0 1 2 3 4
Develop new healing techniques to complement the ones you use already.	0 1 2 3 4
Be proposed for membership of a recognised Professional Association.	0 1 2 3 4
Obtain access to 'Professional Indemnity Insurance.'	0 1 2 3 4

Hypnosis is valuabe for:

Mental and emotional health.	0 1 2 3 4
Physical well-being.	0 1 2 3 4
Creative or educational enterprises.	0 1 2 3 4
Athletic and sports performance.	0 1 2 3 4
Visualising and achieving goals.	0 1 2 3 4
Psychic and spiritual growth.	0 1 2 3 4

Hypnosis will help you to:

Develop and express awareness and intuition.	0 1 2 3 4
Gain a happier homelife. Become a better husband, wife, parent or friend.	0 1 2 3 4
Feel worthwhile, self-confident, zestful.	0 1 2 3 4
Acquire the ability to relax completely in any situation.	0 1 2 3 4
Regain your natural ability to sleep easily.	0 1 2 3 4
Sell yourself, your ideas and your services with confidence and enthusiasm.	0 1 2 3 4
Increase your income and expand your personal relationships.	0 1 2 3 4
Attract and hold worthwhile friendships.	0 1 2 3 4
Improve your ability to concentrate and memorise.	0 1 2 3 4
Analyse your behaviour and its effects on your personal relationships.	0 1 2 3 4
Discover your negative mental patterns, and their effect on your life.	0 1 2 3 4
Free yourself from hostility, resentment, fear of rejection.	0 1 2 3 4
Select your goals in life, chart your course for their realisation.	0 1 2 3 4
Programme your mind with positive mental concepts and success attitudes.	0 1 2 3 4
Make your vital affirmations work for you; achieve self-mastery.	0 1 2 3 4

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0	1	2	3	4	5	6	7

Select the above colours in order of preference e.g. 6 3 4 1 0 7 5 2

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Please note that you may pay by Credit Card, or by sending a Cheque, Postal Order, or Bank Draft to:
The Institute of Clinical Hypnotherapy & Psychotherapy
Therapy House
6 Tuckey Street
Cork City

Payment Method: Credit Card Cheque Bank Draft Postal Order Other *


Please note that applicants outside of Ireland and the UK will need to pay an additional cost to cover Post and Packaging, Details of this cost will be forwarded to you on receipt of your application, or you can contact the ICHP for details of same.

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In the interests of security those paying by Credit Card should
contact the ICHP Administrative offices at +353 (0) 21 4273575 with your card details.

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Send me a copy of this Application Form