Please print this page and send with deposit as necessary

Course Applied for Gestalt Basics

Your Name            Your Date of Birth

Your Address            

Post Code              

Tel Numbers (Home)   (Work)

Email Address         

Current Work Responsibilities

EXPERIENCE OF GESTALT AND/OR HUMANISTIC THERAPY APPROACHES

1. As a Client/Group member   
2. As Trainee                        
3. As Practitioner                   

ANY OTHER RELEVANT PERSONAL GROWTH/TRAINING EXPERIENCE

ANY HISTORY OF TREATMENT FOR A MENTAL HEALTH CONDITION 

ACADEMIC/RELEVANT QUALIFICATIONS

REASONS FOR APPLYING FOR THIS COURSE

HOW DID YOU FIND OUT ABOUT THIS COURSE?

Please print the form:

Return form for Gestalt courses to:
David Kalisch, Buckton Farm House, Sidbury, Sidmouth, Devon, EX10 0PS
Jenny Dawson, 6 Blair Atholl, 20 Douglas Avenue, Exmouth, Devon, EX8 2EY

I enclose a non-refundable booking fee made out to CHPC (to be deducted from the full fee) (please tick appropriate box)

Gestalt Basics £25  
Please invoice: (contact name/address/tel no)