I wish to apply for the following course:

Family Name:

Given Names:

Date of Birth:

Address:

Phone (h): (w):

Fax: Mobile:

Email:

1. Formal educational qualifications:

2. Current occupation:

3. Previous experience (if any) in working with people in a helping
capacity:

4. Experience as a client in personal counselling/psychotherapy and/or personal growth courses:

5. Any other relevant training or experience:

UPON SUBMISSION PLEASE SEND (WITH THE EXACT PERSONAL DETAILS ABOVE) A DEPOSIT OF $100.00 TO:

Somatic Psychotherapy Institute of Australia
Level 1, 215 Darling Street
Balmain NSW 2041

Email: spia@spia.com.au

THE DEPOSIT WILL BE REFUNDED IF YOUR APPLICATION IS UNSUCCESSFUL.