Name:

Email:

Phone:

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Address 2:

City:

State/Province:

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Number of Tickets Wanted (Workshop Price: £ 200):

Are you a mental health professional? Yes No

If so, in which profession?

Are you currently or have been in personal psychotherapy? Yes No

Please give details.

If you answered No to the previous 2 questions, what is your interest in attending this seminar on Bioenergetics?



The C.P.D. certificate will be provided. Please state the name you would like to appear on it:

Please indicate a telephone number for us to contact you for an informal discussion about the training day:

Best time to call: Daytime Evening

Any Other Comments or Questions:

Date on which the cheque will be mailed:

Amount Enclosed: £