Smoking Cessation Client Information Form

Yorkshire Hypnotherapy Training

Keldale House, Beal Lane, Beal, DN14 0SQ
This form is to help me decide if I can offer you a place on a training course with Yorkshire Hypnotherapy Training. You may also be asked to have an informal interview before being considered for a place, especially if we haven't met or spoken before. This is generally done by phone. Please do not pay anything until you have been offered a place.

If you prefer not to submit personal details online, you can download a blank form from the 'enrol now' page of the website and send it to us by post. Thank you.

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Data Protection

Please read my data protection policy on https://www.yorkshirehypnotherapytraining.co.uk/cookies before submitting this form. It tells you how I collect, look after and use your personal data.
Under the GDPR, you need to agree to each separate use of your data. You can withdraw permission for any of these uses at any time by letting YHT know in writing.
I have read your privacy policy and agree to Debbie Waller using my personal data: *

to answer queries and provide you with support to decide if we can offer you a place on one of our courses to administer the course once you are enrolled to collect payment and maintain records to contact any third party involved in your enrolment (e.g. someone who is funding the course)
When we offer you a place, we will also sign you up for the YHT monthly newsletter if you are not already subscribed. We believe this is a legitimate business use of your contact details, but you can opt out if you wish.

That's fine Opt out
Signed (type your name) *
Today's date: *

Day Month Year Date Picker Icon
About you
Your name as you would like it to appear on certificates *
What do you prefer to be called if different (e.g. nickname)?
Email *
example@example.com
The best phone number to contact you *
Is it OK to leave a message on that number? *

Yes No
Address including post code *
Emergency contact (name and phone number) *

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 signing 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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