Booking Form | ‘On Behalf of Our Mothers’

Thank you for taking the time to complete this as honestly and fully as you can. Your details will be held in confidence and will not be shared with any third parties.

Which location is this workshop being held? *

First Name *

Date Of Birth *

Day *

Month *

Year *

Phone Number *

Email Address *

Street Address *

How did you find out about the Workshop? *

Family/FriendOnline SearchDiane, her Website or NewsletterFacebook/Social MediaIntroduction or WebinarNatural Therapy PagesOther

Health

Are you currently seeking Counselling, Coaching or Therapy from any other source? *

If "Yes", please provide details:

Do you have any chronic/recurrent illness &/pain or health concerns? *

If "Yes", please provide details:

Are you taking any medication for a physical or mental health issue? *

If "Yes", please provide details:

And finally, Please add anything else you would like me to know at this point about yourself, your partner (including their name) or your Intentions for the Workshop.

Cancellation Policy

A non-refundable Administration Fee of $75 per person applies to all bookings cancelled after the Early Bird cut-off date.
In the unlikely event that the Workshop is cancelled, you will be refunded in full.
In either instance, you are welcome to transfer the remainder of your fee to the next available Workshop.

Agreements | Please Read Carefully

Ticking the boxes indicates your acceptance of these Agreements.

I acknowledge that I am at least 18 years old.
I have read and accepted the Cancellation Policy.
I agree to respect the confidentiality of all participants in the Workshop.
I understand that everyone in the group is an integral part of the Workshop and agree to be on time and attend for the full duration of the Workshop, including lunchtime.
I understand that as a part of my Workshop commitment I will be receiving course information and support via email and I will open and read them!

Accept all terms & conditions

Payment

Please indicate if you prefer to pay via Direct Credit to my account or - only if using a credit card - via PayPal, and I will forward you an invoice for payment. Please note payment is due on receipt of the invoice for your registration to be complete.

I wish to pay by: *