PROFESSIONAL TRAINING COURSE

IN PSYCHOTHERAPY

APPLICATION FORM

 

Name: …………………………………………………………………………………………………..

Address: …………………………………………………………………………………………………

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Email (applicants must supply an email address) …………………………………………………

Telephone (Day) ……………………………………….. (Evening)…………………………………

Date of Birth: ……………………………………………

 

EDUCATION

Date                                                 Institution                                         Qualification

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WORK EXPERIENCE

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PSYCHOTHERAPY EXPERIENCE (IF ANY)

 

Experience receiving psychotherapy

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PERSONAL DEVELOPMENT

Courses etc. attended for personal development:

Date                                            Title of Course                                    Facilitated by

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Please supply the names and addresses of 2 referees who must not be relatives

Name ……………………………………………   Name …………………………………………….

Address …………………………………………   Address ………………………………………….

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Position …………………………………………   Position …………………………………………..

 

Signature: .………………………………………………………………………………………………

Date: ……………………………………………………………………………………………………..

 

 

PERSONAL STATEMENT (About 200 words)

Please indicate why you wish to be considered for this course, how you have come to apply and if successful what you would hope to do on completion of the course.