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Membership Application.

Fields marked with a '*' are mandatory
Click Here for a PDF file about Membership Requirements.

Your name: *

 
Address: *Telephone: *
Email: *

Please give details of any specialisms:
  Fluent in any languages other than English:
  

What grade of membership are you applying for?

  When did you graduate?
  *
Length of time in practice * years & months 
How many sessions monthly (about) * Teachers only - how many teaching hours monthly?
Your name as you want it to appear on your certificate:

Supervisor's details
Type of Supervision: Differential Peer
When started:
Session frequency and length:
Main modality: Face to Face Telephone Other (please specify):
Please note: Supervision details are subject to a random checking procedure

Details of training(s) (including number of classroom hours and home study hours) :
*
Qualifications & other memberships:
Continual Professional Development:
There is a requirement for a minimum of 15 hours CPD per year
Please list trainings attended in the last 12 months (subject to random checking) *
DECLARATION (subject to randomised checks)

Check all appropriate boxes:
I have not been in continuous practice during the last 24 months.
I have been in continuous practice during the last 24 months.
I have professional indemnity insurance; my certificate number is:
I know of no legal or other reasons why I should not be offered membership.
Signed: * This typed signature signifies that you confirm all details on this form are correct to the best of your knowledge. Where this name does not match that at the top of the form, the application will not be processed.