NB: In addition to filling in this application
form, we request that applicants attach an
up-to-date CV, giving a full employment history, and
two passport photographs.
Please complete the form in black or dark blue ink.
Please return this application to:
The Course Administrator
Northern School of Child & Adolescent Psychotherapy
71 – 75 Clarendon Road
Leeds
LS2 9PL
PART 1
Section 1: Personal Details
Title: / Mr / Mrs / Miss / Ms / Other (please specify):Surname/Family Name:
First/Given Name(s):
Gender: / Male / Female / Date of Birth (DD/MM/YYYY): / / /
Home Address: / Term Address (if different):
Postcode: / Postcode:
Telephone Number (Daytime): / (Mobile):
Email:
Citizenship: / UK citizen / EU citizen / Non-EU citizen
Nationality:
If non-EU citizen, how long have you been resident in the EU?
Section 2: Educational Qualifications
Please list your higher educational achievements, beginning with the highest qualification to date:
Educational Qualifications:Name of institution / Level of award
(i.e. BA/BSC) / Title and year of award / Grade
(i.e. 2:1/Merit)
Please indicate what type of educational institution you have recently attended:
UK state school (4901) / UK HE institution(4941)
UK Independent school(4911) / Any non-UK institution(4931)
UK FE college(4921)
Please indicate your highest educational achievement, to date:
01 Higher degree of UK institution / 02 Postgraduate diploma or certificate, excluding PGCE
03 PGCE with QTS/GTC registration / 04 PGCE without QTS/GTC registration
05 Postgraduate equivalent qualification / 10 Undergraduate qualifications with QTS
11 First degree of UK institution / 12 Graduate degree of EU institution
13 Graduate of other overseas institution / 14 GNVQ/GSVQ level 5
15 NVQ/SVQ level 5 / 16 Graduate equivalent qualification
21 OU credits / 22 Other credits from UK HE institution
23 Certificate/Diploma of education / 24 HNC or HND (including BTEC and SCOTVEC equivalents)
25 Dip HE / 28 Professional qualifications
26 GNVQ/GSVQ level 4 / 27 NVQ/SVQ level 4
29 Foundation course at HE level / 30 Other HE qualification of less than degree standard
43 Foundation course at FE level / 55 GCSE/O level qualifications
44 Access course (QAA recognized) / 56 Other non-standard qualification
45 Access course (not QAA recognized) / 40 Combination of GCE A/SCE higher and GNVQ
47 Baccalaureate / 41 ONC or OND (including BTEC and SCOTVEC equivalents)
48 ACCESS course / 93 Mature student with prior experience
98 No formal qualifications / 97 Other non-UK qualification
31 Foundation degree / 39 A level equivalent
94 Advanced Modern Apprenticeship / 92 Accreditation of Prior (Experiential) Learning (APEL/APL)
Section 3: Current Employment Details
Job Title:
Employer Name:
Employer Address:
Postcode: / Dates of Employment:
Work sector:
NHS: Medical / Social Care
NHS: Allied Professional / Criminal Justice
NHS: Nursing / Nursing – other
Education / Not Employed
Private Practice / Other (please state)
Work Discipline:
Psychiatry(01) / Probation(10)
Clinical Psychology(02) / Social Work(11)
Child Psychotherapy(03) / Police (12)
Nursing(04) / Teaching (13)
GP(05) / Educational Psychology(14)
Counselling(06) / Any Other Discipline (15)
Professions allied to medicine(07) / Non-waged(16)
Clergy (08) / Social care workers(17)
Management Consultancy(09) / Adult Psychotherapy(18)
Section 4: Finance
For all M80N students, UEL registration and course fees will be paid by the NorthernSchool ofChild and Adolescent Psychotherapy.
Section 5: ReferencesPlease give the names and addresses of two people – one of your choice and one from your current work place in a senior position (normally your line manager or supervisor) – and the capacity in which you are known to them. In addition we will seek references from your observation course tutor.
1. Name: / 2. Name:Job title: / Job title:
Address: / Address:
Postcode: / Postcode:
Telephone No: / Telephone No:
Capacity: / Capacity:
Section 6: Additional Information (for UEL purposes)
Have you previously been a student at:
- UEL Yes No
If yes, please provide your previous student number: ______
PART 2
Section 7: Criminal Records Disclosure
Under the provisions of the Rehabilitation of Offenders Act 1974 (exceptions) Order, all students are required to provide information about any convictions, cautions, reprimands and final warnings which for all other purposes are ‘spent’ under the provisions of the act.In order to process your application one of the requirements by NSCAP is to ensure that all students are in possession of an enhanced CRB (Criminal Record Bureau) disclosure that will check the existence and content of any criminal record.
Do you have this disclosure? / Yes / No
If no, have you applied for a disclosure? / Yes / No
Date of application:
Are you currently under investigation for a criminal offence?
Yes / No
Have you ever been convicted of any criminal offence, cautioned, reprimanded or given a final warning by police.
Yes / No
If you have answered YES to either of the above questions, please give details of offences, penalties and dates.
Having a criminal record does not necessarily debar you from being admitted onto this course. However, any information contained on your Disclosure would be considered by NSCAP. Please rest assured that all such cases are considered fully and fairly before reaching a final decision.
If you are successful in obtaining a place with NSCAP then you will also be obliged to report any criminal activity or investigations into criminal activity in which you may be involved during the duration of the course. You are obliged to report this immediately to your tutor, failure to do so could result in exclusion from the course.
Are you aware of any police enquires undertaken following allegations made against you, which may have a bearing on your suitability for a place on this course?
Yes / No
If so, please give details.
Signature:
Date:
Section 8: Student Declaration
Please note that this form will be used as a joint application (to NSCAP) and enrolment form (for UEL/Tavistock) for successful applicants. Please read and sign the following declaration which is a condition of your being admitted to a joint programme of study at the Northern School of Child and Adolescent Psychotherapy and the University of East London/ Tavistock and Portman Foundation NHS Trust.
1. I certify:
(i) that the above information is correct to the best of my knowledge;
(ii) that I have read and accept the terms of admission to the University of East London (overleaf);
2. For the duration of my studies at NSCAP/University of East London/The Tavistock and Portman NHS Trust:
(i) I agree to notify promptly the relevant course administrator
- of any interruption in my studies;
- of any other changes to data submitted previously in respect of my enrolment or circumstances;
(ii) I accept responsibility for payment of my tuition fees or other charges relating to my studies with NSCAP/the University of East London/The Tavistock and Portman NHS Trust**
3. I give my consent for personal data relating to my studies to be collected, processed and published by
NSCAP/the University of East London/The Tavistock and Portman NHS Trust in ways which support the
effective management of its higher education provision, and in accordance with:
(i) terms of the Data Protection Act (1998); and
(ii) any Notification submitted to the Data Protection Commissioner in accordance with this
legislation.
** For all M80N students, UEL registration and course fees will be paid by the NorthernSchool of Child and Adolescent Psychotherapy.
Printname: ______
Signature: ______Date: ______/______/______
TERMS OF ADMISSION TO THE UNIVERSITY OF EAST LONDONImportant: The following provisions form part of the contract between the University of East London and its students.
- Student Status - Students are expected to enrol by the first day of each academic session, or other starting date appropriate to their programme of study. There is no guarantee that their place will be held open beyond this date. Anyone who fails to complete her / his enrolment or to pay fees by the due date, as published in the fees payment policy, may forfeit student status and all rights attaching to that status, including attendance and use of university facilities. This shall apply whether or not a letter of exclusion is issued.
- Proof of Qualifications - Students are required, before they begin their studies, to produce evidence, when requested, of having satisfied the entry requirements as set down in the Prospectus and / or as notified to them by the academic area appropriate to their programme of study. Such evidence must be in the form of the original certificates or, in the case of GC(S)Es, certified notifications of results from the examining body. Anyone discovered to have falsified or misrepresented her / his entry qualifications is liable to expulsion from the University.
- Supplementary Tuition - In addition to the normal curriculum requirements of a programme of study, students who are considered to need supplementary tuition in order to pursue their course will be required to take additional study as prescribed by the university.
- University Regulations, Policies & Rules - Students must agree to abide by the various regulations, policies and rules applicable to them which are in force at the time of their enrolment and as amended throughout the duration of their programme of study. Key documents * are included in the Essential Guide or distributed at enrolment: others specific to particular areas ** will be distributed as students begin to use the relevant facilities. A complete set is available for inspection, or for reference on request, in the Department of Student Administration.(Examples - the lists are not exhaustive - include:
*Manual of General Regulations and Policies (incorporating, inter alia, procedures for academic appeals, assessment offences, complaints, disciplinaries); fees payment policy (including late payment charges and instalment payments); equal opportunities policy; anti-harassment policy; no-smoking policy; Student Charter
**Specific course requirements for attendance, assessment and additional charges: library rules; network security policy; laboratory and workshop codes of practice)
- Data Protection - Students must supply, and promptly notify any change(s) to, the data required by the university for official recording and external reporting purposes, which include the processing of such data for any purposes connected with their studies or for health and safety reasons or for any other legitimate reason. Information held regarding students will only be released under the terms of the university’s registration under the Data Protection Act. These terms are consistent with the university’s commitment to prevent fraud and the abuse of public funds.
- Changes to Scheduled Courses - The university reserves the right to modify and develop its advertised courses (including the location of delivery) and to cancel a proposed course if it reasonably considers this to be necessary. If the course to which the student has been admitted is cancelled, the student may withdraw from the university without any liability for fees, or transfer to another course on which a place is available and for which the student is suitably qualified.
- Disruption of Scheduled Activities - The university will endeavour to provide the services and functions described in its literature. However, it cannot be held accountable for frustrations of these services and functions which occur through circumstances outside its control.
- Funding Arrangements for Full-Time Home Undergraduate & PGCE Students – Students should contact their local education authority (LEA) in the first instance. The LEA will determine the student’s eligibility for financial help with fees and living costs. Students should apply to their LEA for a student loan at the same time an application is made for support with tuition fees.
Section 9: Additional Information
1. Please list any professional qualification(s) and date obtained
DATE / AWARDING BODY
2. Where did you undertake the observation course?
3. Name of Observation Course Tutor:
Seminar / No. of terms completed / Seminar leader
Infant Observation
Work Discussion
Young Child Observation
Psychoanalytic Theory Year I
Psychoanalytic Theory Year II
Personality Development
Child DevelopmentResearch
4. Written work
You are required to submit 4 essays. Students who are in the final year of the observation course and who may not have completed all of the required papers should submit with the application all those papers that are available and then submit the remaining papers as soon as they are completed.
Please indicate which papers are being submitted with your application:
Infant Observation / Work Discussion / Psychoanalytic Theory / Child Development Research
5. Please give details of other events attended (e.g. supervision, individual or small groups, relevant external studies, Group Relations events, NSCAP conferences):
6. Please give details of your experience of working with children and adolescents, including details of the age range involved
Dates / Institution / Your Role / Full or part-time
State hrs/days per week / Age of children/adolescents worked with in this post
7. Why are you applying for the clinical training at this point in time?
Please answer this question on a separate (type written) sheet.
8. What particularly draws you to this profession?
Please answer this question on a separate (type written) sheet.
9. Are you at present having personal analysis? YES / NO
Number of sessions per week:
EQUAL OPPORTUNITIES MONITORING INFORMATION
Full Name:
Please use block capitals and underline your family name
Course applied for:
We are committed to policies and practices aimed at increasing the number of students from black and ethnic minority backgrounds who study with us. Your help in completing the following questions will enable us to monitor the effectiveness of our recruitment and admissions policies. The information you provide will be treated as confidential information, and will be detached from your application form before tutors shortlist candidates for interview. The data will be stored in confidence by the Directorate of Training and Postgraduate Education, and will be used by the Higher Education Statistical Agency (HESA), NSCAP and The Tavistock and Portman NHS Trust for statistical purposes.
If you object to providing this information please indicate this in the box provided.
Please state your nationality or, if a holder of dual nationality, please indicate your country ofbirth:
Please state which country you regard as your permanent home:
Ethnic Origin (please tick one box only):
White – British (11) / Asian or Asian British - Indian (31)White - Irish (12) / Asian or Asian British - Pakistani (32)
White - Scottish (13) / Asian or Asian British - Bangladeshi (33)
Irish Traveller (14) / Chinese (34)
Other White Background (19) / Other Asian Background (39)
Mixed - White and Black Caribbean (41) / Black or Black British - Caribbean (21)
Mixed - White and Black African (42) / Black or Black British - African (22)
Mixed - White and Asian (43) / Other Black Background (29)
Other Mixed Background (49) / Other Ethnic Background (80)
Not Known (90) / Information Refused (98)
If you ticked number (19), (29), (39), (49) or (80), please describe your ethnic origin using your
own words:
CHECK LIST
Please ensure that you have dealt with the following:
Application form completed
Completed equal opportunities monitoring form
2 passport-sized photographs attached with name and course
written on the back
Up-to-date CV, with full employment history
Criminal Records Bureau section completed
Please return all parts of this application to:
The Course Administrator
Northern School of Child & Adolescent Psychotherapy
71 – 75 Clarendon Road
Leeds
LS2 9PL
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