The School of Infant Mental Health

The School of Infant Mental Health

Application Form 2013

Course

Please indicate the course that you are applying for:

□Diploma in Infant Mental Health and Psychoanalytic Parent Infant Psychotherapy (Four years, leading to accreditation with the UKCP as a Parent Infant Psychotherapist)

□Diploma in Infant Mental Health (Two years)

□Conversion course in Psychoanalytic Parent Infant Psychotherapy (Two years, leading to accreditation with the UKCP as a Parent Infant Psychotherapist)

□Diploma in Infant Observation (One or two years)

Do you want to study:

□London-based□Online (English)□Online (Spanish)

Section 1:Personal Details

Title:Mr □Mrs □Miss □Ms □Other ______

Surname: ______

First name: ______

Gender:Male □Female□D.O.B.______/______/______

Home Address:Organisation address:

______

______

Postcode: ______Postcode: ______

Telephone No: (daytime)______(Mobile) ______

Email: ______

Nationality:UK citizen □EU citizen □Non-EU citizen □

Section 2: Education

Please list educational achievements (continue on a separate sheet if necessary):

Name of School/Institution / Level of Award / Title and year / Grade i.e. GCSE/NVQ
2:1/Merit etc.

Section 3: Work Experience and/or Professional Experience

Please list relevant work or professional experience (continue on a separate sheet if necessary):

Employer / Role / Dates

If relevant, has your current employer agreed:

• To give you the time (if necessary) to attend during working hours? Yes □ No□
• For you to bring discussion material relating to your current work? Yes □ No □

Please indicate:

Current job title: ______

Name and address of current employer:

______

______

Postcode: ______Dates of employment: ______

Section 4: Finance

Who will be responsible for your fees?You □Your Sponsor □

Please give name and address of your sponsor (if applicable): ______

______

______Postcode ______

Please state what arrangements you will make for payment of your fees if your sponsor’s funding is withdrawn for any reason.

______

______

Section 5: References

Please give names and addresses of two people who may be contacted for a reference.

1. Name:______2. Name: ______

Job title:______Job title: ______

Address:______Address: ______

______

______Postcode: ______Postcode: ______

Email address: ______Email address: ______

Phone: ______Phone: ______

Capacity: ______Capacity: ______

Section 6: Statement

Please tell us on a separate sheet why you would like to undertake this training.

Section 7: Declaration

Please read and sign the following declaration which is a condition of your being accepted as a Student at the School of Infant Mental Health.

I certify that:

• The information I have given is correct to the best of my knowledge

• For the duration of my studies at The School of Infant Mental HealthI agree to notify the Course Tutor:

• of any interruption to my studies
• of any other change in my circumstances

I accept responsibility for the payment of fees and any other charges relevant to the Course.

Signature: ______

(Please print Name) ______

Date: ______

Please return this form,along with a payment of £100, to:

The Administrator

The School of Infant Mental Health

27 Frognal

London NW3 6AR

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