Smoking Cessation Client Information Form

About you
Are you over 21? *

Yes No
Have you been to a YHT Taster Day? *

Yes No
Do you have any other experience of hypnosis or hypnotherapy? *

Yes No
Are you trained in any other kind of therapy? *

Yes No
Why do you think you should be offered a place? (This is your chance to sell yourself: tell us about your skills or experience and/or why you would like to come on the course)
If there is any other information you'd like to give that didn't fit on the form, please put it here.
Declaration

By submitting this form you are accepting that places are offered on the basis of the information you supply and affirming that this is true and complete.

You are also accepting that the format, date and venue choices are offered on a provisional basis since classes can only run if student numbers are viable.

PLEASE NOTE. Email is pretty reliable but very occasionally messages go astray. If you have not received our reply to this form within 48 hours, please phone Debbie on 01977 678593

A word before you press the 'submit' button!
A copy of this form will be sent to you, but since it contains sensitive data it will be password protected. The password you need to open it is YHT (capital letters, case sensitive).
I suggest you write that down now as it won't be in the email; if you mislay it, you can always request it from Debbie.
Should be Empty:

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