Clinician registration Home Clinician zone Registration Clinician zone Step 1 of 7 - Your Details 14% TitlePlease selectMrMrsMissDrProfMsFirst Name* Surname* Gender*Please selectMaleFemalePrefer not to sayEthnicity*Prefer not to answerWhite: BritishArabAsian: BangladeshiAsian: ChineseAsian: IndianAsian: PakistaniBlack: AfricanBlack: CaribbeanMixed: White & AsianMixed: White & BlackOther Asian backgroundOther Black backgroundOther Ethnic groupOther Mixed backgroundOther White backgroundWhite: GypsyWhite: IrishWhite: Irish TravellerDate of birth* DD slash MM slash YYYY Mobile Phone Number*Emergency Contact Number*Email Address* Secretary Email Address (if applicable) Home / Correspondence AddressPostcode* House Name / Number* Street Name (Required)* Town* County* Country Specialisms(Please select multiple options where applicable)SpecialismPlease selectChartered PsychologistClinical PsychologistCounselling PsychologistPractitioner PsychologistConsultant PsychologistOccupational PsychologistChild PsychologistCounsellorCBT TherapistEMDR TherapistHypnotherapistNeuropsychologistPsychiatristArts TherapistPsychotherapistPsychological Wellbeing PractitionerPlay TherapistInterpersonal Psychotherapy TherapistOccupational TherapistSpecialism 2Please selectChartered PsychologistClinical PsychologistCounselling PsychologistPractitioner PsychologistConsultant PsychologistOccupational PsychologistChild PsychologistCounsellorCBT TherapistEMDR TherapistHypnotherapistNeuropsychologistPsychiatristArts TherapistPsychotherapistPsychological Wellbeing PractitionerPlay TherapistInterpersonal Psychotherapy TherapistOccupational TherapistSpecialism 3Please selectChartered PsychologistClinical PsychologistCounselling PsychologistPractitioner PsychologistConsultant PsychologistOccupational PsychologistChild PsychologistCounsellorCBT TherapistEMDR TherapistHypnotherapistNeuropsychologistPsychiatristArts TherapistPsychotherapistPsychological Wellbeing PractitionerPlay TherapistInterpersonal Psychotherapy TherapistOccupational TherapistClinical ExpertisePlease only tick EMDR if you are accredited to Level 2 or above/ Please only state that you can provide CBT if you're accredited with the BABCP or HCPC* CBT EMDR Counseling Psychiatric CAT ACT Neuropsychology Family therapy Addictions- Drugs/Alcohol Addictions- Other Bipolar Eating Disorder Gender Diversity Long Term Health Conditions Neuro Diversity Schizophrenia Other Interpersonal Psychotherapy Critical Incident Stress Management trained (CISM) Body dysmorphic disorder EMDR Training statusPlease select...Fully TrainedIn trainingNot TrainedContactedUpload EMDR CertificateAccepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 10 MB.If other please specifyWhat age clients do you see?* Minor (under 12) Adolescent (13-17) Adult (18+) Adult (65+) Are you prepared to provide home visits?* Yes No Do you speak any other languages? Yes No If yes, please tick which languages you speak: Arabic Bengali Catonese Farsi French German Hindi Italian Mandarin Polish Portuguese Punjabi Romanian Russian Slovakian Spanish Turkish Urdu Welsh Other If other please specifyWould you be willing to provide telephone treatment. Yes No Would you be willing to provide Secure Video Conferencing treatment i.e Skype? Yes No Would you be interested in providing Telephonic Clinical Pathway Assessments? Yes No a brief telephonic clinical pathway assessment to determine which evidence based clinical pathway is most appropriate for the symptoms being experiencedDo you have experience providing cCBT^? Yes No ^ Computerised Cognitive Behavioural Therapist via an online platformIf yes where and what service? BABCP Expiry Date MM slash DD slash YYYY HCPC Expiry Date MM slash DD slash YYYY BPS Expiry Date MM slash DD slash YYYY BACP - Accredited members only. Expiry Date MM slash DD slash YYYY UKCP Expiry Date MM slash DD slash YYYY EMDR Expiry Date MM slash DD slash YYYY GMC Expiry Date MM slash DD slash YYYY NCS Expiry Date MM slash DD slash YYYY ICO Registration number ICO Expiry date MM slash DD slash YYYY Attach ICO registration documentAccepted file types: pdf, doc, txt, docx, dot, xml, Max. file size: 10 MB.IPT-UK IPT-UK Expiry date MM slash DD slash YYYY Adult Safeguarding Level 3 certified Yes No Attach Adult Safeguarding Level 3 CertificateAccepted file types: pdf, doc, txt, docx, dot, xml, Max. file size: 10 MB.Child Safeguarding Level 3 certified Yes No Attach Child Safeguarding Level 3 CertificateAccepted file types: pdf, doc, txt, docx, dot, xml, Max. file size: 10 MB. Clinic Address(First clinic address)Postcode* House Number* Street Name* Town* County* Country Is this your home address?* Yes No Disabled access?* Yes No Parking available?* Yes No Is there a waiting area? Yes No Attach clinic room photo(s) both Internal and External (up to 4 photos. If not submitted with your application it will be required at a later date.) Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, Max. file size: 10 MB, Max. files: 4. Clinic Address(Second clinic address. Optional)Postcode House Number Street Name Town County Country Disabled access? Yes No Parking available? Yes No Is there a waiting area? Yes No Attach clinic room photo(s) both Internal and External (up to 4 photos) Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, Max. file size: 10 MB, Max. files: 4. Clinic Address(Third clinic address. Optional)Postcode House Number Street Name Town County Country Disabled access? Yes No Parking available? Yes No Is there a waiting area? Yes No Attach clinic room photo(s) both Internal and External (up to 4 photos) Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, Max. file size: 10 MB, Max. files: 4. Clinic Address(Fourth clinic address. Optional)Postcode House Number Street Name Town County Country Disabled access? Yes No Parking available? Yes No Is there a waiting area? Yes No Attach clinic room photo(s) both Internal and External (up to 4 photos) Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, Max. file size: 10 MB, Max. files: 4. Please only complete this section in you are a Psychologist Registered with the HCPC or a Psychiatrist registered with the GMC.Are you interested in providing Expert Psychological Reports? Yes No A legal report produced for the courts by an experienced Expert WitnessDo you have any experience? Yes No Please detail what experience you haveWould you be willing to provide this type of assessment via the telephone? Yes No CV* Drop files here or Select files Accepted file types: pdf, doc, docx, txt, dot, Max. file size: 10 MB, Max. files: 4. Professional Indemnity insurance* Drop files here or Select files Accepted file types: pdf, doc, docx, txt, dot, jpg, jpeg, png, Max. file size: 10 MB, Max. files: 4. Insurance Name Amount of Policy Expiry Date DD slash MM slash YYYY Proof of Right to work in the UK (If not submitted with your application it will be required at a later date)Accepted file types: jpg, jpeg, png, pdf, Max. file size: 10 MB.Please Specify document typePassport photocopyPhotocopy of NI cardBirth certificateDBS / CRB Certificate (If you have one)Accepted file types: jpg, jpeg, png, pdf, Max. file size: 10 MB.DBS number Type of DBS Standard Enhanced Date of DBS MM slash DD slash YYYY * I confirm that the information above is accurate to the best of my knowledge and belief. I understand that false information may result in withdrawal or refusal of your registration.*Are you subject to any pending or existing Professional Disciplinary action?* Yes No If Yes, please provide further information...Do you have any criminal convictions, other than motoring offences?* Yes No If Yes, please provide further information...Do you comply with General Data Protection Regulation? (Further due diligence will be requested following submission)* Yes No How did you hear about us?Please selectBPS advertBABCP advertBACP advertBABCP conferenceContact from CBT ClinicsFriend referralOtherIf you have been provided with an ENQ reference number, please enter here: Hiddenamex CommentsThis field is for validation purposes and should be left unchanged.
