Your Name

Address for Correspondence

Practice Address(s)

(What you wish to have shown on the database)

Telephone Number

Mobile Number

Fax Number

Web Site Address

Please enter the details for your web site Directory. Up to 100 words (for examples please see the Directory HERE)

Memberships to other Associations

 Public Liability Insurance Company

(Mandatory requirement)

Once you press the submit button you will be taken to the payment page with World Pay or PayPal secure servers

* Please send copies of your Hypnotherapy and/or Past Life Therapy Qualifications and a photo of yourself (if desired) via email attachment HERE.

 This is a mandatory requirement, applications will not be considered without this.

Not required for previous PLTA students

Application for Membership