MEMBERSHIP APPLICATION
FORM
MEMBERSHIP
FEE IS £10.00 PER YEAR FOR UK RESIDENTS, £15.00 FOR EUROPE AND £20.00 OUTSIDE
EUROPE.
PLEASE COMPLETE THE FORM IN
BLOCK CAPITALS
MR/MRS, ETC: ..................................... FORENAME/GIVEN NAME: ..........................................……
SURNAME:
.................................................................................................. D.O.B.: .........................
ADDRESS:
...........................................................................................................................................
..............................................................................................................................................................
.............................................................................................................................................................
POST CODE:
.................................................... TELEPHONE NO; ....................................................
SIGNATURE:
........................................................................ DATE:
.........................................
TYPE OF DISORDER,
PLEASE CIRCLE AS APPROPRIATE ( UP TO A MAXIMUM OF 5 )
|
01 |
agoraphobia |
|
14 |
driving |
|
27 |
moths |
|
40 |
thunder
/ lightning |
|
02 |
bees
& wasps |
|
15 |
eating |
|
28 |
mice |
|
41 |
tranx
withdrawal |
|
03 |
birds |
|
16 |
feeling
unreal |
|
29 |
noise |
|
42 |
vomit |
|
04 |
blood |
|
17 |
flying |
|
30 |
o.c.d.
( thoughts ) |
|
43 |
wind
/ weather |
|
05 |
blushing |
|
18 |
frogs |
|
31 |
panic |
|
44 |
carer
( o.c.d. ) |
|
06 |
body
defects |
|
19 |
general
anxiety |
|
32 |
relaxation |
|
45 |
carer
( panic ) |
|
07 |
cats |
|
20 |
heights |
|
33 |
schools |
|
46 |
carer
( phobia ) |
|
08 |
children
fears |
|
21 |
hospitals |
|
34 |
sexual |
|
47 |
anxiety
in children |
|
09 |
claustrophobia |
|
22 |
hyperventilation |
|
35 |
snakes |
|
48 |
o.c.d. (hoarding) |
|
10 |
daddy
long legs |
|
23 |
illness
& death |
|
36 |
social |
|
49 |
o.c.d.(contamination) |
|
11 |
darkness |
|
24 |
injections |
|
37 |
space |
|
50 |
o.c.d.
( checking ) |
|
12 |
dentists |
|
25 |
insects |
|
38 |
sphincteric |
|
51 |
o.c.d.
( counting ) |
|
13 |
dogs |
|
26 |
monophobia |
|
39 |
spiders |
|
52 |
o.c.d.
(symmetry ) |
Please tick this box
if you want a Telephone Recovery Group Application Form: [ ]
Please return this form together with the Optional
Contact Booklet Form (if you wish your details to appear in it),
the Information Booklet Form, the Audiocassette Form, The videocasstte form,
the Membership Fee and a Large (9 x 6)
Stamped Self Addressed Envelope to:
The
Membership Secretary, No Panic, 93 Brands Farm Way, Telford, Shropshire,
England, TF3 2JQ.
Cheques/Postal Orders should be made payable to No Panic.
For those people wishing to join
or the renew their membership please note:
Telephone orders using credit or debit cards are welcome - simply
telephone
the No Panic Office on 01952 590005.
Between 9am - 5pm, Mon - Friday.