Banyan Hypnosis Center for Training & Services, Inc.
1431 Warner Ave. Suite E, Tustin, CA 92780

• Register by calling our office, or print out  this form and send it by FAX, mail, or e-mail.  

• Please, if you have any questions at all, give us a call and we will be happy to answer them.

OFFICE:  (800) 965-3390
                  (714) 258-8380
FAX:         (714) 258-8374
WEB:        www.HypnosisCenter.com
Contact us by E-Mail

  Application For Enrollment In Hypnotherapy Certification Training
100 hours of Hypnosis and Hypnotherapy training (classroom and assigned) for certification by the National Guild of Hypnotists
(Section I And II as described in our catalogue)

 Name (Please print your name as you would like it to appear on your certificate)

 _______________________________________________________________________

 Address

 Street __________________________________________________________________

           __________________________________________________________________

 City, State (or Province), Zip Code (or equivalent) and Country (if outside of USA)

 _________________________________,  ______________________,  _____________
(City)                                                                                  (State)                                                  (Zip)

 ________________________________________________________
(Country)

 Telephone Numbers

 Daytime Telephone Number _________________________________

 Nighttime Telephone Number ________________________________

 FAX Telephone Number ____________________________________

 E-Mail Address ___________________________________________

 Answering the following questions will help us to provide a better training experience.  Answering the next 6 questions is optional but encouraged.

1.  How did you hear about this training? ______________________________________

 2.  Are you now certified in hypnosis or hypnotherapy? ___________________________

 3.  If so, where were you trained and when? ____________________________________

 ________________________________________________________________________

 4.  Are you currently in practice as a hypnotist, hypnotherapist or psychotherapist (or other mental health or medical practitioner)?  Please explain the nature of your practice.

________________________________________________________________________

________________________________________________________________________

5.  Are you a licensed professional such as Psychologist, Counselor, Nurse, or Doctor?  If so, please let us know what profession you are licensed in.

________________________________________________________________________

6.  Are you considering opening a hypnosis/hypnotherapy practice in the next 12 months or adding these skills to an already established practice?  If so tell us about it.

________________________________________________________________________

Tuition

Tuition for the certification course is $1995.  Choosing Payment Option A will save you $200, and choosing Payment Option B will save you $100. 

Payment Information

Check one: ___ Visa ___ MasterCard___ American Express___ Sending in a check

Credit Card No.: __________-___________-__________-___________
                                                                                                                               

Expiration Date: _____/______ CCD No.__________________________
                                                                       (3 digit no. on back of card)

Name as it appears on card: _______________________________________________

Signature: _________________________________________ Date ________________