Northern Programme for Art Psychotherapy

Complete all sections using BLOCK CAPITALS and typescript or black ink for clarity and ease of copying.

* indicates a Mandatory Field / App. No.

1. PERSONAL DETAILS

Title:* / Mr / Miss / Mrs / Ms / Dr / other:
Family Name(s)* / Sex* / Male / Female
First Name(s)* / Date of birth*
dd/mm/yyyy
Previous Family Name(s)
Email* / Mobile No.
Have you previously been at Leeds Beckett?* / YES / NO
Leeds Beckett Student No (if applicable and if known)

2. FEE STATUS

This section helps to identify your status for fees purposes, i.e. how much you will pay if you enrol onto a course at Leeds Beckett University. Please complete the Country of Birth and Nationality sections. If you were not born in the European Union, please ensure that you complete the date of entry fields. If we need further information with regard to your fee status, you will be contacted by the Student Admissions Team.

I am a permanent Resident*
Select the category which applies to you / Inside the UK / Inside the EU / Outside the EU
Country of Birth*
Nationality*
If not born in the UK, date of first entry to live in the UK* dd/mm/yyyy
Do you have an unrestricted right to live in the UK?* / YES / NO
Who is expected to pay your fees?* / Self / Employer / Sponsor /

3. CONTACT DETAILS

Correspondence address / Home address – permanent residence (if different)
Country / Country
Postcode (UK only) / Postcode (UK only)
Dates at this address / Dates at this address

4. COURSE APPLIED FOR

Course title / MA ART PSYCHOTHERAPY PRACTICE (ARPYS) / For office use
SCH / AWSID / MODE / ST
Location / NORTHERN PROGRAMME, SHEFFIELD / Entry level/year / 1
Full-time (FT) or
Part-time (PT) / Month & year course
starts (eg Sept 2016)

How did you find out about the University and these courses? Tick as applicable:

o School/College / o Education Fair / o Friends/Family
o Advertisement / o Website – Leeds Beckett/Other*:
o Agent / o Other

5. EDUCATIONAL INSTITUTIONS ATTENDED SINCE AGE 11

Name of school,
college or university / Location incl. country,
(eg Penang, Malaysia) / From / To / Full-time (FT)
Part-time (PT)
Distance learning (DL)
Month / Year / Month / Year
1 / FT / PT / DL
2 / FT / PT / DL
3 / FT / PT / DL
4 / FT / PT / DL
5 / FT / PT / DL
6 / FT / PT / DL

6. QUALIFICATIONS

Please enter your previous and intended qualifications, starting with the most recent. Please continue on a separate sheet if necessary. Underline the qualification which you consider satisfies the University’s English Language Requirement (GCSE grade C or equivalent).

PLEASE INCLUDE A COPY OF YOUR DEGREE CERTIFICATE(S) WITH YOUR APPLICATION.

Institution (number as in section 4) / Taken / to be taken / Awarding body (if not the institution where studied) / Level/Award (eg GCSE, GCE, BSc) / Subject/unit/module/component / Result grade (Leave blank if not yet achieved)
Month / Year

7. RELEVANT WORK EXPERIENCE

Name &
location of organisation / Position/
Job Title / Type of work/duties / From / To / Full-time (FT)/
Part-time (PT)
Month / Year / Month / Year
FT / PT *
FT / PT *
FT / PT *
FT / PT *
FT / PT *
FT / PT *

8. PERSONAL DEVELOPMENT

Please enter here any further information you may wish to offer in support of your application. We are particularly interested in your reasons for choosing the course, your career aspirations and other information relevant to your application which you have been unable to provide elsewhere on this form. If you have been out of formal education for some time, please outline any relevant experience that may be taken into account in lieu of formal qualifications.

9. ADDITIONAL REQUIREMENTS

Please enclose three short pieces of writing of no more than 750 words each with this application. It is not necessary to strive after literary excellence or correct essay style. Please try to convey what you mean in your own words.

1. Please review a piece of work of your choice – whether art, literature, music or film – highlighting any psychological aspects of the work. Please do not send previously written material, ie dissertations, past course essays, etc.

2. On the basis of your own personal experience, how do you think someone experiencing a difficult time in their life could be helped?

3. Please enclose 6 photographic prints of your art work. Write about the essential themes underlying your artistic practice and any psychological insights you may have gained from it.

Any other information relevant to this application should be attached on a separate sheet of paper.

9. APPLICANT DECLARATION

I agree that by signing below, I am giving the University permission to use my personal information for the purpose of processing my application. Including all of the University’s online systems, for which I will receive email notifications, and, if I am offered a place at the University which I then accept, will form part of my University student record.

I confirm that the information given on the form is true, complete and accurate and no relevant information has been omitted. I understand that this application or any subsequent university place offered may be withdrawn by Leeds Beckett University if in the future the information provided proves to be inaccurate, either intentionally or unintentionally.

Applicant’s signature / Date

10. DURATION IN CARE

If you have spent any time in care, please indicate the total length of time below:

We treat this information in confidence and may use this information to contact you to discuss whether or not you may require any extra resources or support to undertake your chosen course. We will not use this information to determine whether or not to make you an offer of a place.

Less than 1 week / 1 year ─ 3 years
1 week ─ 3 months / 3 years or more
3 months ─ 1 year / I have not spent any time in care
Information not provided

11. CRIMINAL CONVICTIONS

Please note that the University operates in accordance with legislation concerned with the rehabilitation of offenders and often having a criminal record is not a bar to entry. However, we do need to ensure that all declarations of criminal records are properly investigated in order to discharge our duty of care to other members of the University community. Please do not give details here; if you declare an unspent criminal conviction you will be contacted separately.

Do you have any criminal convictions that are not spent? / Yes / No

12. DISABILITY INFORMATION

Please give details of any help you may need

0 / No Known Disability
1 / Learning Difficulty e.g. dyslexia
2 / Autistic Spectrum or Asperger Syndrome
3 / Long Standing Illness
4 / Mental Health condition
T / Physical Impairment
6 / Deaf/Hearing Impairment
7 / Blind/Visual Impairment
8 / Two or more of the above
9 / Disability, Special Need or Medical Condition not listed above

13. ETHNICITY

White / Black/Black British ─ Caribbean / Asian/Asian British Indian / Mixed – White/Black Caribbean
Gypsy/Traveller / Black/Black British ─ African / Asian/Asian British Pakistani / Mixed – White/ Black African
Not Known / Other Black Background / Asian/Asian British Bangladeshi / Mixed – White/Asian
Information Refused / Other Asian Background / Chinese / Other Mixed Background

14. REFERENCES

References are an integral and important part of the admission process. The information contained helps to guide University staff in making their decisions. In order for us to evaluate your academic and intellectual capacity effectively, references should if possible cover:

(i) Suitability for the course(s) applied for;

(ii) Intellectual qualities, including:

a. development to date and previous examination performance, with special reference to any factors which may have adversely influenced the result

b. present performance

c. future potential, including an assessment of the probable results of any pending qualifications to be taken

(iii) Personal qualities

(iv) Career aspirations

(v) Health and other personal circumstance relevant to the application

(vi) Social and other interests

Please supply the names and contact details of 2 referees:

Name of Referee 1:
Post/occupation/relationship
to applicant:
Name of institution/organisation:
Address:
Postcode:
Telephone:
Email address:
Name of Referee 2:
Post/occupation/relationship
to applicant:
Name of institution/organisation:
Address:
Postcode:
Telephone:
Email address:

N.B. If you are invited for interview, it is your responsibility to ask your referees to supply references.

· The reference must be supplied on official headed paper and must be signed by the referee.

· The reference must be supplied in a sealed envelope and sent directly to the Administrator at the address below.

Please return your completed application (comprising application form, copy of degree certificate(s) and all the additional requirements) by post to:

The Administrator, Art Therapy Northern Programme

Netherthorpe House, 101 Netherthorpe Road

Sheffield S3 7EZ