Radiant Wellness Hypnosis Institute Ltd

Change your mind. Change your life.

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Radiant Wellness Hypnosis Institute Hypnosis Training Application
Please complete and attach all required documentation.
Return application and $25.00 application fee to:
Office use only
Date received____________
Ra
adiant Wellness Hypnosis In
nstitute Ltd.
Application completed and signed
269
Rialto
Drive
$75 application fee received
Ponte Vedra Beach, FL 32082
$200 reservation received
(904)280-4230
Application approved
C
h
a
n
ge@RWHypnosis.com
Date approved_________
Acceptance letter sent
A $200.00 deposit holds your place in the training. Balance 7 days prior to the first day of training.

First Name________________________________________________

Wed like to have a photo

of you before you arrive. It
is for reference only and is
not considered in the
screening process.

Last Name________________________________________________
Date of birth_______________________________________________
Address__________________________________________________
City ________________State___________ Zip code_______________

Please attach here.

Home phone ___________________Cell phone___________________
Work phone ____________________E-mail______________________
Current occupation (if not currently employed, your vocation training or profession).___________________________

How do you plan to incorporate Hypnosis into your personal life or professional practice?______________________

Program information
Dates you would like to attend:_____________________________________________________________________

How did you find out about Radiant W ellness Hypnosis Institute Ltd
training____________________________________
_____________________________________________________________________________________________

Prerequisite information
What would you like to most gain from the training?____________________________________________________

What is your personal intention for taking the training program and how do you imagine that it will impact your life
personally, professionally, socially, and emotionally?

Other relevant education and/or training (indicate type, level, and length of training).

Health Information
Describe your present state of health:_______________________________________________________________

Yes No

Physical Limitation; chronic pain, disabilities?

Yes No

Serious illness, injury or major surgery within the last three years?

Yes No

Under medical treatment or supervision for:

Yes No

Current psychotherapy, counseling or psychiatric treatment:

Yes No

Hospitalization for psychiatric care within the last three years:

Health Information (continued)

Yes No

Do you have a communicable disease?______________________________________________

Yes No

Are you recovering from an addiction? If yes how long have you been in recovery?

List any prescription medications you are currently taking and indicate dosage and frequency of intake (we do not
need to know about birth control or cosmetic prescriptions).

Describe your weekly alcohol consumption.

____________________________________________________________________________________

Please check and explain the following conditions that apply to you:

Allergies:____________________________

Intestinal conditions:____________________________

Arthritis:_____________________________

Osteoporosis:_________________________________

Asthma:__________________

Recent injuries:________________________________

Chronic sinus condition:_________________

Recent surgery:_______________________________

Diabetes:_____________________________

Spinal conditions:______________________________

Endocrine conditions:___________________

Ulcers:_______________________________________

Epilepsy:_____________________________

Urinary conditions:______________________________

Glaucoma:____________________________

WOMEN ONLY:

Hernia:_______________________________

menstrual conditions:___________________________

Hypoglycemia:_____________________

PMS Symptoms:_______________________________

Heart conditions:_______________________

Pregnant (due date):____________________________

High blood pressure:____________________

Hysterectomy:_________________________________

Low blood pressure:_____________

Menopause symptoms:_________________

Please describe any other physical or mental conditions that would be helpful for your instructor to be aware of. List
any medications you are taking and the conditions you are taking them for.

In case of emergency, please contact:

Name:

Relationship:

Telephone:

Physician:

Telephone:

Therapist:

Telephone:

I certify that the above information is true and complete to the best of my knowledge and that I will not hold Radiant
Wellness Hypnos s nstitute Ltd, or my instructor liable for any mishaps arising from my participation in hypnosis
instruction.
Signature___________________________________________________Date_______________________________