UKCP Five Year Re-accreditation 2017

First Names / Surname
Address:
Email:Tel:
Please tick box if these details have changed in the last 12 months
Modality you are registered as: Integrative [ ] orOther (please specify) …………………………
Other UKCP Colleges/sections you are registered with, if any?
Date first registered with UKCP
UKCP registration No:
Have you registered with RSPP in the last year?
If not, please give a reason: / Yes [ ] No [ ]
Complaints
(please read the following and advise if any apply to you and provide details)
Complaints: Have there been any complaints made against you?
Disciplined by a professional body: Have you been disciplined by ant professional body or member organisation responsible for regulating or licensing a health or social care profession?
Criminal offences and cautions: Have you been convicted of a criminal offence, received a conditional discharge for an offence, or accepted a police caution?
Suspension and restrictions: Have you been suspended or placed under a practice restriction by an employer or similar organisation because of concerns relating to your practice of psychotherapy, competence or health? / Yes [ ] No [ ]
Yes [ ] No [ ]
Yes [ ] No [ ]
Yes [ ] No [ ]

PRIVATE CLIENT WORK

Please complete the following for the period 1st July 2012 to 30th June 2017:
Private Clinical Work / No of Hours
Direct client work: specify hours of direct clinical contact.
Supervision given: Please give the number of hours of supervision you provided to individuals, groups and/or peers (if any):

SUPERVISION RECEIVED

(This section must be completed by the supervisor and supported by a letter from them on your clinical practice)

Name of Supervisor:

Address:

Period of supervision: from to

Hours of supervision during this period:

Frequency (weekly, monthly, etc.)

I confirm this registrant has been in supervision as stated above

SignedDate

Name of any additional Supervisor (if applicable):

Address:

Period of supervision: from to

Hours of supervision during this period:

Frequency (weekly, monthly, etc.)

I confirm this registrant has been in supervision as stated above

SignedDate

INSTITUTIONAL CLINICAL WORK

Institutional Clinical Work
(Clinical work within an organisational setting such as NHS, charities, other agencies) / No of Hours
Title of the post held (e.g. psychotherapist, supervisor, manager); the name of the organisation and a brief description, with a breakdown of the clinical work undertaken (e.g. assessment, client work, or supervision

SUPERVISION RECEIVED

(This section must be completed by the supervisor and supported by a letter from them on your clinical practice)

Name of Supervisor:

Address:

Period of supervision: from to

Hours of supervision during this period:

Frequency (weekly, monthly, etc.)

I confirm this registrant has been in supervision as stated above

SignedDate

Name of any additional Supervisor (if applicable):

Address:

Period of supervision: from to

Hours of supervision during this period:

Frequency (weekly, monthly, etc.)

I confirm this registrant has been in supervision as stated above

SignedDate

CONTINUAL PROFESSIONAL DEVELOPMENT

Personal reflection on learning and continuing professional development

This could include personal therapy, other forms of personal contemplation or practice, and any experiences that have enriched your work as a therapist.

This should include how your CPD reflects your approach to diversity and equality anddemonstrate an understanding of the needs of a diverse client population. (Minimum of 750 words to be attached to this application)

INSURANCE
Insurance Company:
Policy number:
Please provide a copy of your insurance certificate
Professional Will Arrangements
Please indicate if you have made arrangements for clients in the event of long term absence from work. This is something to consider. / This section must be completed in full; membership renewal will not be approved without current insurance cover and copy of Certificate.
Subscription
Pay the re-accreditationfee on-line via our online store:
and click on ‘University Services’ / Yes [ ]
Declaration
I confirm that the above application is correct to the best of my knowledge. I understand RSPP reserves the right to check any of the above information and that if any statements prove to be false membership of both the RSPP and UKCP will be jeopardised. / Signed:______
Date:______
Please return to:
RSPP/UKCP Senior Faculty Administrator
Regents School of Psychotherapy and Psychology
Regent's University London
Inner Circle
Regent's Park
London NW1 4NS
Or by email electronically to

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Continual Professional Development

Schedule of Activities

(Please refer to the enclosed RSPP CPD PolicyJuly 2017)

Name: Year: July 2012 – June 2017

CPD Activity:
Description and rationale / Title & Location / Hours / Category / Evidence provided
(Continuous work in a therapeutic capacity – mandatory)
(Mandatory receipt of appropriate levels of clinical supervision)
(please detail activities 2-8 below)

Please keep a copy for your records with corroborating materials.

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