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General Registration and Application Form

Please complete all sections. Attach separate sheets if space is not sufficient.


I wish to apply for the following course:

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Family Name......................................................................................................

Given names......................................................................................................


Age.......................................


Address...............................................................................................................

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Phone (h)................................................. (w).....................................................


Fax............................................................ Mobile...............................................



Email....................................


Date......................................

Signature.............................


1. Formal educational qualifications:

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2. Current occupation:

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

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

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5. Any other relevant training or experience:

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PLEASE RETURN COMPLETED APPLICATION FORM WITH 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.