Pink Therapy Sup

Supervision of Sexual Minority Therapy
Application Form

Please print this form out and post it in to us.

Please reserve me a place on the following workshop(s)

Date:________________________

Name:____________________________ Email Address:_____________________________

Postal Address: ______________________________________________________________

___________________________________________________________________________

Postcode:____________________________

Telephone No:________________________Home
Telephone No:________________________ Work
Telephone No:________________________ Mobile

It would be helpful to the facilitator in planning this workshop to know a bit more about you, if you are willing to share this information:
Do you have any issues/dilemmas which you would particularly like to see addressed on this workshop?

_______________________________________________________________________________________________________

Occupation:____________________________ Theoretical Model: ______________________

Sexual Orientation:_______________________ Gender Identity:________________________

I am/am not a member of the Directory of Pink Therapists (please delete as applicable)

I enclose a cheque payable to: Pink Therapy for £105 per workshop (if you are a member of the Directory of Pink Therapists or £115 if you a non-member.

Signed: _____________________________ Today's Date: ____________________________

Please post this form, along with your fee to:

Dominic Davies
Pink Therapy
Flat 3
3-4 Archer Street
London
W1D 7AP

Terms and Conditions
Fees: The full fee for each workshop is £105 per day for members of the Directory of Pink Therapists or £115 for everyone else. Cheques should be made payable to Pink Therapy in GB sterling. Payment must accompany all orders, and we are not able to invoice you.
Receipts: A receipt will be sent along with your booking confirmation and details of the venue.
Cancellations: There is an adminsitrative charge of £15.00 per person for cancellations received in writing up to one month prior to this event. Thereafter no refund is possible.
Indemnity: This booking constitutes a legally binding contract. It may be necessary, for reasons beyond the control of PInk Therapy to change the programme, speaker, date or venue. In the unlikely event of a programme being cancelled, a full refund will be made, but Pink Therapy disclaims any further liability.
To change a delegate, please call at least seven days prior to the event.

Pink Therapy reserves the right to amend, change or cancel workshops or trainers at its own discretion due to circumstances beyond our control.