Personal Information

Thank you for your interest in joining SELF WORK SESSIONS - the 6 week course that begins on Thursday 9th March 2017

Please complete this form as honestly as possible.  Your answers will remain confidential and are only used for the purpose of supporting you.

We will email you once we receive your details.

Please email courses@mb-therapy.co.uk or call 07414 660 134  if you have any questions.

Full Name

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* 1. Full Name

Date of Birth

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* 2. Date of Birth

Address

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* 3. Address

Mobile Number

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* 4. Mobile Number

Email Address

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* 5. Email Address

What would you like to achieve by attending this course?

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* 6. What would you like to achieve by attending this course?

Please describe any special assistance you require

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* 7. Please describe any special assistance you require

Mental health history - Have you been treated for any of the following (check all that apply):

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* 8. Mental health history - Have you been treated for any of the following (check all that apply):

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