NYSEPH
New York Milton H. Erickson Society for Hypnosis and Psychotherapy
30 West 60th Street, Suite 1R, New York, NY 10023
Tel: 212-873-6459............ Fax: 212-535-0783
TRAINING INSTITUTE APPLICATION FORM
Class schedule:
_____Monday, October 20th, 2008---10
A.M. to 12 P.M.
___Monday, October 20th, 2008---6 P.M. to 8 P.M.
or
.____Wednesday,October 22nd, 2008---10 A.M. to 12 P.M.
___Wednesday, October 22nd, 2008---6 P.M. to 8 P.M...
Please put numbers 1, 2, 3 and 4 in front of the times in
order of preference.
The times will be determined as the classes fill up.
Date:_________________________
Last Name____________________________First Name_____________________Middle
Initial______________
Major/Degree________________________License Number:__________________________________________
Address_____________________________Apt. #_____City__________________State_____Zip___________
Phone #____________________Cell#____________________E-mail_______________________________
1.How did you hear about the NYSEPH Training
Program? Journal Ad____Website____Recommendation____
Other______________________________________________________________________________
2.My educational background and degrees:_______________________________________________________
3. I am presently working in : Private practice____Agency____Hospital_____Hospice____Other__________
Please give details:_________________________________________________________________________
4. 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 mail to:
Brigitte E. Lifschitz, LCSW,
NYSEPH Training Program,
30 West 60th Street, Suite 1R,
New York, NY 10023