Application for Admission & Student Contract

Clinical Hypnosis Institute

(586) 899-9009

Please Print Clearly:

First Name: _____________________ Middle __________ Last Name: ______________________

                                                                  (Name or Initial)

Mailing Address:  

___________________________________________     ___________________    _________    ____________

Street or P.O. Box                                                                          City                             State                  Zip


Home Phone: _____________________ Work Phone: _______________________ Cell Ph: ______++________


e-mail address: ____________________________________ Web site:   http://www. _______________________

Marital Status:      Married ___          Single ___                 Date of Birth: __________________

Years of school completed:  _______

 Employer: __________________________________    Occupation: ____________________________________

 Are you now or have you ever been under the care of a Psychiatrist?       No ___    Yes ___   

If yes, please give details of your condition, inclusive dates of treatment, and list any medications prescribed: ___________________________________________________________________________________________________________________  

Reason for taking this course:


Have you ever been convicted of a Felony?        No  __    Yes__   If yes, please give details:  


I certify that the information on this application is complete and accurate to the best of my knowledge.  I understand that misrepresentations on this form may be cause for refusal of admission or immediate suspension from the course.   

Each Module is $995.00.  There are three Modules that lead to certification as a hypnotherapist.

I enclose a check or money order made out to Clinical Care Network LLC for $100.00  as a deposit for Module I  and agree that the balance of monies due for each module is to be paid not later than the first day of the module unless prior arrangements have been made.  

Refund policy.  

All tuition and fees paid by the applicant shall be refunded if the applicant is rejected by the school before enrollment. An application fee of not more than $25.00 may be retained by the school if the application is denied.  All tuition and fees paid by the applicant shall be refunded if requested within three business days after signing a contract with the school. All refunds shall be returned within 30 days.  No refunds will be made after the first day the course begins.  At the discretion of the instructor, a student who leaves mid-course for personal reasons may be reinstated where s/he left off during the next term of classes at that level

I have read and understand the School Catalogue and student handbook of Clinical Hypnosis Institute policies and agree to abide by them and to the terms of this contract:   

Applicant Signature: __________________________________________ Date: ____________________



For Clinical Hypnosis Institute School Use Only  

Application Accepted ___             Application Denied ___             Date:______________

School Administrative Director: ______________________________________________

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