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: 212-794-0143, Fax: 212-535-0783

Winter 60-hour Intensive Hypnosis Classes will begin on Friday, February 24, 2012
10 A.M. - 2 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......................................................................................................................................

Full tuition for the first 3 sections is $2100. There is a deposit of $700 for section I. Please make checks payable to "NYSEPH" in the amount of $700.00 for the first section.
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