www.MINDbasedHealing.orginfo@mindbasedhealing.org(415)6992574

577SoquelAve.SantaCruz,CA95062

MEDICALHYPNOTHERAPYTRAINING

APPLICATION

Name:________________________________________________________Date:_________________________

Address:______________________________________________________________________________________

Emailaddress:__________________________________________Phone:___________________________

Profession___________________________________________________________

Howdidyoulearnaboutthetraining?____________________________________________________

TypeofPayment:____$695fullpayment____$249monthlyinstallments(Youwillreceiveaninvoiceviaemailonceapproved)

Pleasesendanemailtoinfo@mindbasedhealing.organdincludethefollowing:

• List of training in hypnosis / hypnotherapy, neurolinguistic programming(NLP),coaching,psychotherapy,andanyothertrainingyoufeelispertinent

• Copyofcertificationsinhypnosis/hypnotherapyandNLP(Pdforphotographofthecertificateisacceptable).

• Describeyourexperience(years,numberandtypeofclients,etc)youhaveinutilizing your training in NLP and hypnotherapy. This is only additionalinformation to help the trainer understand the level of experience of thepractitionerstobettersupportyourlearningandpracticebuilding.