YHT Volunteer form

Thanks for your interest in becoming a case study for one of our students.
The following form asks you some questions so we can consider if hypnotherapy is the right way forward for you, as well as checking that your situation is one that our students can work with.
We cannot guarantee to place you with a student, sometimes students have already arranged all the volunteers that they need, or the timing isn't right, but we will do our best. If we can't help immediately we'll keep your details on our list for up to 6 months.

Data Protection
The GDPR (General Data Protection Regulations) says that we need to collect your information to hold and process your personal data, and also for each separate use we make of them. Our full Data Protection Policy is on our website at https://www.yorkshirehypnotherapytraining.co.uk/cookies but in brief:
• we'll hold this data for seven years in secure storage,
• only Debbie Waller of Yorkshire Hypnotherapy Training and the student you work with will be given access to the data on this form,
• your general situation may be discussed in a lesson but no personal details will be used so your identity will be protected,
• when students write up a case study they use an alias to refer to you, so your identity is protected,
• the student you work with will need to gather more detailed information from you and they’ll talk to you about their methods of protecting it,
• they may share this further information with Debbie Waller if they need to seek advice or support whilst working with you, and it will be seen by the person marking their case study.

Your full name*

Email address*

Confirmation Email

Phone number *

Full Address*

Please include your FULL address with post code so I can match you with someone local if you prefer to work face to face. We can only accept volunteers who live in the UK.

Safety check *

	Yes	No	Not sure
Do you have unspent convictions under the Rehabilitation of Offenders Act 1974
Do you take regular or long term medication?
In the last two years have you undertaken psychotherapy, counselling or hypnotherapy?
Have you ever suffered from addictions (other than smoking)?
Have you ever been diagnosed with a personality disorder or psychosis?
Have you ever been diagnosed with type 1 diabetes or epilepsy?
Do you have any other long term health issues (physical or psychological)?
Do you need support to access therapy?
Have you been hypnotised before?
Are you over 18 years of age?

If you have answered yes to any of the above, please give details and dates where appropriate

Please give a brief outline of the issue/s would you like to address *

(e.g. what it is, how long you’ve had the issue, what you have tried to deal with it before, and with what results?)

Is there a specific time limit on when you need to achieve your goal (e.g. if you want to deal with driving test nerves, when is your test?).

How would you prefer to see a therapist?*

I would prefer local, in-person, appointmentsI would prefer to work onlineEither of the above would be fineOther

DATA PROTECTION

Before submitting this form, please read our Data Protection Policy

I have read your privacy policy and agree that*

	Yes	No
the data on this form can be used by YHT to assess my suitability to work with a student
the data can be passed to a student who is willing to work with me
any further data I share with that student can be discussed with a YHT tutor for purposes of student support, supervision and training
my situation can be discussed anonymously in the classroom for training purposes
my work with a YHT student can be written up anonymously as a case study
I understand providing this information does not guarantee that a student will be able to work with me
I understand that working with a student on a particular issue does not guarantee any particular outcome to the therapy

Please verify that you are human*

Volunteering for Yorkshire Hypnotherapy Training