www.MINDbasedHealing.org [email protected] (415) 699 2574 577 Soquel Ave. Santa Cruz, CA 95062 MEDICAL HYPNOTHERAPY TRAINING APPLICATION Name: ________________________________________________________ Date: _________________________ Address: ______________________________________________________________________________________ Email address: __________________________________________Phone: ___________________________ Profession ___________________________________________________________ How did you learn about the training? ____________________________________________________ Type of Payment: ____ $695 full payment ____ $249 monthly installments (You will receive an invoice via email once approved) Please send an email to [email protected] and include the following: • List of training in hypnosis / hypnotherapy, neurolinguistic programming (NLP), coaching, psychotherapy, and any other training you feel is pertinent • Copy of certifications in hypnosis/hypnotherapy and NLP (Pdf or photograph of the certificate is acceptable). • Describe your experience (years, number and type of clients, etc) you have in utilizing your training in NLP and hypnotherapy. This is only additional information to help the trainer understand the level of experience of the practitioners to better support your learning and practice building.