Division of Clinical Psychology

Application to be a National Assessor for Applied Consultant Psychologist posts in Health & Social Care and Higher Education

Please attach your current CV giving details of your qualifications, career history, continuous professional development and publications.

Note: A copy of this application form will be sent to your named referees.

Section one - Personal details
Please provide an address and contact details that you would wish to be presented on the register (which is available to the general public via the Society’s web-site).
Name: Membership number:
Address:
Telephone: Fax:
E Mail:
Mobile:
Region:
(i.e. Eastern, London, N. Ireland, North West,Northern & Yorkshire, Scotland, South East, South West, Trent, Wales, West Midlands)
Date first appointed to Consultant Grade B or Band 8c or above:
Present post:
What is your primary role:
(i.e.Director/Head of Service/Specialists Consultant)
In which Sector is the post:
(i.e.NHS/ 3rd Sector/ Independent Private Practice)
Section 2 – Qualifications
Please indicate your principal or dual qualification (i.e. Clinical, Health, Counselling)
Section three – Area of work
Please indicate the section of the list you wish to be considered for.
Note: You must be working at least 5 sessions a week in the speciality, except for management responsibilities where a minimum of 3 is acceptable. Please indicate your 1st and if appropriate, your 2nd choice (it is only possible to apply for a maximum of two sections so the register at this time).
Adult Mental Health (General) / Management
Adult Mental Health (Psychotherapy) / Clinical Health Psychology
Adult Mental Health (Psychosis and Complex Mental Health) / Neuropsychology and Neurological Rehabilitation
Children and Young People / Primary Care
Forensic / Primary Care - Psychotherapy
Learning Disability / Services for Older People
Teaching, Training and Research / Health Psychology
Counselling Psychology / Substance Misuse and Addictive Behaviour
Section four – Specialist expertise
If appropriate please indicate your specialist expertise within your speciality listed above e.g. Child Neuropsychology, pain clinics, eating disorders.
Section five – Training
Please indicate when, and to what level you were last trained in the following skills:
Recruitment and selection (including interviewing skills):
Equal opportunities and discrimination legislation:
Diversity including, gender, race, religion, disability and sexual orientation:
Section six – Additional experience
What additional experience do you have which is relevant to your proposed role as a National Assessor? What attracted you to apply? Please give examples of CPD and evidence of competence.
Section 7 – Recruitment and selection training
Please give details of your experience, over the last three years, of being a member of an interview panel, and any recruitment and selection training undertaken
Date / Post being recruited. e.g. Clinical Psychologist Band 8c and above. / Your status on the panel e.g. service head, potential colleague, clinical expert / Status of other panel members e.g. Department head, Clinical Director, Psychiatrist
Section 8 – Conduct
Are you currently undergoing any investigatory procedures?
Yes / No
If you are then please give brief details below.
Section nine – Referees
Please provide the names of two referees for each section of the list you wish to be considered for.
Referees must be Consultants (or equivalent in senior course staff for university posts) who can verify the information on your application. Referees should not normally have personal connections with the applicant. You may provide one referee for two sections if this is appropriate.
Name:
Address:
Phone:
Fax:
E mail:
Section of list:
Post held by referee: / Name:
Address:
Phone:
Fax:
E mail:
Section of list:
Post held by referee:
Name:
Address:
Phone:
Fax:
E mail:
Section of list:
Post held by referee: / Name:
Address:
Phone:
Fax:
E mail:
Section of list:
Post held by referee:

Signature: Date:

Please sign and return this form, together with your CV, to:

National Assessors

The British Psychological Society

St Andrews House

48 Princess Road East

Leicester LE1 7DR

e:

Please mark the envelope private and confidential