ASSOCIATION FOR GROUP AND INDIVIDUAL
PSYCHOTHERAPY
Application
for Professional Training Course
Full Name: Title:
Address:
Home Tel: Work
Tel: Email
address:
Date of Birth: Age:
PRESENT EMPLOYMENT
Nature of
employment:
Name &
Address of employer:
Is
psychotherapy a part of your employment environment?
If so,
explain how:
EMPLOYMENT HISTORY
Please
state the last two posts you held and your reasons for leaving each:
1.
2.
Please
describe any work experience, paid or voluntary, which is relevant to
psychotherapy:
Education
(any post-secondary qualifications and/or professional training)
NB. You
will need to supply, with your application, copies of certificates or
officially signed ratification on headed notepaper of all further education and
professional qualifications and courses that you wish AGIP to recognise. Please
do not send in your application until you have this documentation ready to include.
Each copy needs to be signed by one of your referees.
PSYCHOTHERAPY HISTORY
1. Please
give the following information concerning your psychotherapy experience: Group
or individual:
Starting
& terminating dates:
Name &
Address of therapist:
Therapist's
orientation & professional association:
Frequency:
2. Please give the name, address, orientation
and professional association of your proposed training therapist (See 'Notes
for Applicants')
3. In about
500 words, describe your background and present life, making mention of the
experiences which you feel have helped you become the person you are now,
including those which have been difficult to surmount
(PLEASE
ATTACH YOUR STATEMENT TO THIS FORM)
4. Please indicate where you heard
about the AGIP training course (e.g. advertisement, directory, etc.)
REFERENCES
The
Training Committee requires you to provide the names of two people, not your
therapist, who know you well in a working capacity e.g. line manager,
supervisor, tutor etc.
|
Name: Address: Tel: Relationship
to you |
Name: Address: Tel: Relationship
to you: |
DECLARATION
I declare
that the information given above is an honest statement about myself, I wish to be considered for the AGIP Training
course, and will post my application fee of £95.
Signed: Date:
Please
return to: office@agip.org.uk
Company Limited by Guarantee No.
3863068. Registered Charity No. 1083030