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MEMBERSHIP APPLICATION FORM

MEMBERSHIP FEE IS £12.00 PER YEAR.

MR/MRS, ETC: *                       

FORENAME/GIVEN NAME: * 

SURNAME: *                            

DATE OF BIRTH:    

ADDRESS:*
                                    

POST CODE: *                                   

TELEPHONE NO: *             

EMAIL ADDRESS:  

* - Required information

TYPE OF DISORDER, PLEASE TICK 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

other

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 )

 

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