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* School:
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* Intake:
e.g. BS75

* Title:
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* Gender:
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* 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?

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

* I understand 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 V1.9.

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