Registration

Name *

Address Line 1 *

Address Line 2

City *

State *

Postcode *

Country *

Home Phone

Mobile Phone *

Email Address *

Age

Gender

Ethnic Background

Other ethnic background:

Marital Status:

Highest level of education completed

Occupation:

Religious Preference

Are you currently being treated by a physician or counsellor?

Have you previously been diagnosed with any mental disorders? (select all that apply)

Please specify other psychological disorder:

Have you ever attempted suicide?

If "Yes", how long ago did you attempt suicide?

Are you considering suicide now?

Please read the following statements and initial to indicate your agreement:

The Nedley Depression and Anxiety Recovery Program™ is a unique educational program that teaches the causes of depression.

Name

Phone

Relationship to you

* Limited sponsored positions available. Please discuss with our team.
Other resources will be available during the program.

Account details for Direct Bank Transfer:
Account Name: Bowral Adventist Church
BSB: 032-716 Account: 164883
Reference: “LIFE Surname”