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docleaf Associate Network Application Form

This application form is avalible for download please click here to download

Personal Details

Surname

Forename

Date of Birth

Gender
Male Female
Citizenship(s)

Work Permit(s) Held

Your first language

Other languages

National Insurance Number

Home Address

Postcode

Country

Home Telephone Number

Next of Kin / Emergency Contact

Drivers Licence
Yes No
Any travel related issues (do you require a visa to any countries)

Can you travel at short noticed
Yes No
Nearest UK Departure Airport

Please list any vaccinations

Your passport number

Please list any illness and/or any medication taken

Professional Details
Office Address

Post Code

Country

Telephone

Fax

Mobile

Email Address

Please indicate any particular preferences with regard to contacting you by telephone at home/business
Supervisors Name

Address

Post Code

Country

Please describe your supervision arrangements

Educational & Professional Qualifications

Degree and Subject Area	Date Conferred DD/MM/YYYY	Name of Institution	Address of Institution	Qualification Obtained

General Counselling Experience

Training or Experience	Organisation or Institution	Address of Organisation or Institution	Dates DD/MM/YYYY	Certificate Obtained

Trauma Counselling Experience

Training or Experience	Organisation or Institution	Address of Organisation or Institution	Dates DD/MM/YYYY	Certificate Obtained

Debreifing & Defusing Experience

What Is Your View On Debriefing & Defusion

Have You Been Training Using TRiM Assessment Model

Additional Speciality Areas

Training or Experience	Organisation or Institution	Address of Organisation or Institution	Dates DD/MM/YYYY	Certificate Obtained

Please provide details of two professional referees including your supervisor
Referee 1
Firstname

Surname

Address

Post Code

Country

Please tick here if the above referee provides you with supervision

Referee 2
Firstname

Surname

Address

Post Code

Country

Please tick here if the above referee provides you with supervision

Areas Of Experience
(please tick any of the boxes below that apply to you)
Alcohol/substance misuse
Anxiety Disorders
Bereavement Issues
Child Abuse Victim
Child Abuse Perpetrator
Couples Therapy
Critical Incident Stress Debriefing
Eating Disorders
Family Therapy
Family/Victim Violence
Gay/Lesbian Issues
Group Therapy
Infertility Issues
Depression
Mediation
Organisational Training
Separation/Divorce
Sexual Abuse
Short Term Focus Therapy
Stress Management/Relaxation
Terminal Illness
PTSD
Other: (Please specify)

Please describe your theoretical approach

Hours available for Trauma/EAP work (please state days/times)

Please complete the section below to highlight any Experience/Training past or present work with an EAP.

EAP Training or Experience	Organisation or Institution	Address of Organisation or Institution	Dates MM/YYYY	Certificate Obtained

Professional Membership

Name	Organisation’s Address	Membership Effective Dates

Insurance Cover
Professional Liability Insurance (Please attach Copy)
Insurer

Policy Number

Coverage per incident

Effective Dates
From

To

Additional Information
Please respond to the following questions, attaching an explanation and relevant correspondence where you have ticked a YES box

Has your professional licence, accreditation or membership ever been revoked, suspended or subject to probation or any conditions or limitations?
Yes No

Have you ever voluntarily surrendered you licence or authority to practice?
Yes No
Have you ever had a complaint filed with your licensing or governing body?
Yes No

Has any professional liability insurer or carrier made an out of court settlement or paid a judgement of professional liability claim on your behalf?
Yes No

Have you ever been denied professional liability insurance, or has your insurance ever been cancelled or refused renewal?
Yes No

Have you ever been the subject of disciplinary proceedings by any professional association?
Yes No

What are your office hours? (Please give clear details – times and days)

Details Of Counselling Premises
Please use a separate form for each address
Main Location

Post Code

Country

Tel

Fax

Mobile

Do you answer your phone during business hours?
Yes No
If ‘NO’ please explain how your calls are managed

Type Of Premises
Own separate business address
Dedicated room at home
Other room at home
Rented room at someone else’s business address
Please describe your premises. Please comment on heating, lighting, furnishing and any other aspects you wish to highlight

Please describe your facilities in the criteria indicated below
Access on foot

Access to public transport

Access through to counselling room

Waiting area if any

Disabled access/parking

Personal security in general area

Access to toilet facilities

Likely noise levels from neighbours/telephones/pets/children etc

What are your security arrangements for clients’ notes/records?

(Please use a separate form for each address)
Please give details of the fees charged in private work
Private Counselling Rates
£
Critical Incident Service Rates
£

Sign Off
Signing this form indicates your agreement for us to hold this information on our secure database in both electronic and written formats
Accept Yes

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