Breaking Free Registration Form

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Name:
You can say as much or as little as you like here. Sometimes stating your intention clearly can help bring focus and the power of the course can already start to work for you.
Please respond to any of the following that is applicable to you and provide any relevant details. Are you currently involved in any form of therapy or treatment or have you ever consulted a psychiatrist or psychotherapist/counsellor in the past or suffered from a mental illness? (past or present) Are you currently taking prescribed medication of any kind?