Student Personal Details Form

* Mandatory fields

* School:
—Please choose an option—BelfastBirminghamBrightonBristolCardiffChesterDublinEdinburghEssexGlasgowHampshireKentLeedsLiverpoolLondonManchesterNewcastleNorwichNottinghamOxfordPeterboroughPlymouthSheffieldSurreyWatford

* Intake:

e.g. BS86, LS10, SH5 etc. Please ask your School what your intake number is if you do not know it to fill in this field correctly.

* Title:
—Please choose an option—MrMrsMsMissDrProfRev

* Gender:
—Please choose an option—FemaleMaleTransgenderNon-binary/non-conformingPrefer not to respond

* First name:

* Last Name:

* Address:

* Postcode:

* Telephone – Home:

* Telephone – Mobile:

* Email:

* Please confirm your Email:

* Date of birth:

Person to contact in case of emergency:

* Name:

* Telephone:

Give brief details of your education history, subjects you have studied and any qualifications or awards gained:

Have you had, or do you have any serious illness (including psychiatric/emotional)?

Are you on any medication?

Do you have any learning disabilities (dyslexia, ADHD etc)?

Do you have any special accessibility requirements?

* How did you hear about CPHT?

Have you seen us anywhere else?
FacebookInstagramCoursecheckGoogleYellAssociations (AfSFH, NCH etc.)

Is there any other information you might think is relevant / interesting for us to know?

I hereby consent to any photos taken by CPHT during the course to be used in their marketing material.

I hereby consent to any video recordings made by CPHT during the course to be used in their marketing material.

* I hereby consent to receiving Solution Focused Hypnotherapy from qualified therapists and fellow students in training.

* I understand and acknowledge that once I commence the course, the full course fees remain payable, regardless of whether I am paying in instalments, choose to withdraw, or defer to a future intake.

* I understand and acknowledge that CPHT will process and store my data in line with their Privacy Policy V1.2 and have read and agree to their Terms and Conditions V2.3. The Terms and Conditions are important so please take time to read through them.

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