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Which course are you applying for?
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First Name:
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Surname:
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Title:
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Address:
(House/Street)
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Town / City:
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County:
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Post Code:
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Date Of Birth:
(Optional)
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Occupation:
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Telephone - Day:
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Telephone - Evening:
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Email Address:
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How did you hear about the Experiential Group?
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Friend
GP
Therapist
Advertisement (Which publication?)
Web site (Whose site?)
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Have you ever been in individual therapy / counselling?
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Yes
No |
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Have you ever been in group therapy?
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Yes
No |
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If 'yes', do you know what type of therapy / counselling?
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Psychoanalytic
Rogerian
Eclectic
Gestalt
Other - Please state below
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For how long were you in therapy / counselling?
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If you are no longer in therapy / counselling please
indicate briefly your reasons for leaving.
This is an optional question.
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Do you have any medical condition that you think it
would be helpful for us to know about?
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Yes
No |
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If yes, please state what (eg. epilepsy, diabetes,
asthma, mental health problems etc)
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Are you presently taking prescribed medicine?
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Yes
No |
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If so, please state what
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This experiential; group offers the opportunity to
examine your life and the way you relate to others. As part of the preparation
for this, please use this space to write down any issues you wish to
explore, your expectations, hopes and fears.
Please also indicate what support you have (eg family, friends, GP,
therapist)
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Have you ever applied for, or participated in, any
other Gestalt Centre groups or courses?
If so, please state which group or course, (including dates and the
name(s) of the facilitator(s) if known.)
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Yes
No
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