New Road Psychotherapy Applicant Form Today's Date MM DD YYYY Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Your email * Contact Number(s) * Date of Birth * dd/mm/yyyy MM DD YYYY In what capacity are you seeking to work at NRPC? * Please check box that applies Private Therapist Placement Not sure If seeking to work at NRPC in a private capacity, will you be bringing your own clients? Professional Identity if graduated or once graduated * Humanistic Counsellor, Integrative Counsellor, Psychodynamic Counsellor, Psychotherapist etc What year of your training are you in or how long ago did you graduate? * Name of your training organisation(s) you have trained with or are training in. * Member of/Registered with: * Are you are willing to obtain Professional Liability insurance before you begin working at NRPC? * If I am planning to work with clients under 18, I will submit a DBS certificate once accepted. * Yes N/A Trained to work with? (adults, couples, groups, young people. etc) * Briefly, what formal counselling experience, if any, do you have in working with clients? * Experience/special interest in? * Approximately how many hours of personal therapy have you had since your training started? * FOR THOSE SEEKING A PLACEMENT. Are you able to commit to seeing a minimum of four low-cost clients per week? * For those seeking a placement Yes No N/A FOR THOSE SEEKING A PLACEMENT. We currently provide supervision groups at the times below. Would you be able to attend one of them? * If none, would you be willing to organise and pay for your own private supervision? - select yes or no Fridays 9:30am-11:20am Fridays 11am-12:50pm Wednesdays 4pm-5:50pm Thursday 10am-11:50am None (please also select yes/no below) Yes No N/A What is your general availability to see clients at NRPC like? * When would you be ready to start seeing clients at NRPC? * What appeals to you working at New Road Psychotherapy Centre? * Do you know anyone working at NRPC where there could be a boundary issue? i.e. current or past therapist or supervisor? * Reference: We would like two references, one from one of your training tutors and the other from someone who has knowledge of your counselling skills. The second person would preferably be a placement manager or supervisor. If you have no references like that, a colleague on your course will do. Please supply Name, Position and Email address of the two people willing to offer you a reference. * Thank you for your application.If you have not done so already, please send your pdf CV to juliana@newroadpsychotherapy.comWe’ll be in touch shortly. If you would like to recieve updates and news about courses and events happening at New Road Psychotherapy sign up to our mailing list below Email Address Sign Up We respect your privacy. Thank you!
