NYSEPH TRAINING INSTITUTE APPLICATION FORM
New York Milton H. Erickson Society for Hypnosis and Psychotherapy
Co-Directors of Training:
Brigitte LIfschitz, LCSW E-mail: nysephinfo@earthlink.net
Judith Grosz, LCSW Tel: 212-873-6459, Fax: 212-535-0783
Spring Hypnosis Classes begin on Wednesday, March 17th, 2010
6 P.M. - 8 P.M.
PLEASE PRINT INFORMATION CLEARLY
Date:
...................................
Last Name
....................................
First Name
......................................
Middle
Initial
..........
Major/Degree
.......................................................
License Number:
......................................
Address, Apt #..........................................................................................................
City......................................State...................... Zip....................................
Phone #......................................Cell #.................................
E-mail..............................................
Please check all that apply:
How did you hear about the NYSEPH Training
Program?
Journal Ad
Website
Recommendation
Other.........................................................................................
My educational background and degrees:..............................................
Please check all that apply:
I am presently working in :
Private practice
Agency
Hospital
Hospice
Other: Please give details...........................................................................
My experience in the practice of hypnosis,
if any...........................................................................
.......................................................................................................................................................
Describe the kind of practice you have if other
than psychotherapy......................................................................................................................................
Please make checks payable to "NYSEPH" in the amount of $700.00.
Non-refundable deposit will be returned if applicant is not accepted into the
program.
Please print form and mail to:
Judith Grosz, LCSW,
NYSEPH Training Program, 605 East 82nd Street, #4A , New York, NY 10028