(please print this form using the 'print' option under the 'file' menu of your web browser)
Name: ______________________________________________
Address:____________________________________________
Town_______________________________________________
County\postcode_____________________________________
Tel:____________________ email______________________
Date:_______________________________________________
I would like to reserve a place on (course name)_________________________________ Which is to be held on (date) ___________________________
I have enclosed a non-refundable deposit of £30.00; I am aware that the remainder of the fee should be paid no later than two weeks prior to the course start date.
All cheques should be made payable to ‘Paul Henderson’.
This form should be returned to:
Paul Henderson, 60 Marlborough Rd, Tuebrook, Liverpool, Merseyside L13 8ED.
along with the questionaire and deposit Your place will be confirmed in writing on receipt of your application.
(optional, but recommended)
The following information will be treated in the strictest of confidence
1. Age?
2. Occupation?
3. Are you experiencing or have you ever experienced problems of a psychological, emotional or psychic nature? If so please give details.
4. Are you undergoing any therapy? If so please provide
Details.
5. Are you taking medication if so please give details
6. Have you ever attended any experiential groups? If so
please give details.
7. How/where did you hear about the course?
Thank you for your co-operation
Look forward to meeting you shortly