*ACP 360 Without Service User Feedback for Those with Limited Patient Contact

Enrolment Form for Individuals

Title:
First Name:
Surname:
Telephone no:
GMC Number:
E-mail (essential):
NB: Please use a personal email address to which we can send all communication regarding your assessment.
Trust/ Organisation:
Address 1:
Address 2:
Address 3:
Address 4:
Post code:
Job Title:
Job Grade:
Speciality (Please choose one):
General Adult / CAMHS / Forensic
Older Adult / Learning disability / Rehabilitation
Substance Misuse / Liaison / Psychotherapy
Academic / Medical Management / Other
If you have answered ‘other’ please specify:
Please choose a version of ACP 360:
General Adult / Child & Adolescent
Learning disability / 270 Version*

(*ACP 360 without service user feedback for those with limited patient contact)

The ACP 360 assessment uses questionnaires which elicit numerical responses, and colleagues and patients are invited to provide free-text comments about what they perceive to be your strengths and areas for development. These free-text comments, along with your report, can be sent directly to your appraiser via the system. To do this, please supply the name and email address of the person in your organisation to whom we can send the report (e.g. your line manager, or the person responsible for your annual appraisal). You can add these details later if they are not currently known.
Name:
Telephone number:
Email:
I wish to pay my registration fee of £105 + VAT (e.g. 105+20% VAT=£126)
Cheque (payable to ‘The Royal College of Psychiatrists’)
Credit/Debit card (please note that we do not accept AMEX)
Card number:
Cardholder Name:
Expiry date (mm/yy):
Security Code:
I confirm my enrolment in ACP 360
Signature:

If you are an organisation/Trust wishing to sign up multiple consultants, please contact the team.

Please email or send this completed form to: or to ACP 360, Royal College of Psychiatrists,Centre for Quality Improvement

2nd Floor, Prescot Street, London, E1 8BB.

Charity registration no. 228636