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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