Available start date *

MM

DD

YYYY

Name *

First Name

Last Name

Date of birth (DOB) *

MM

DD

YYYY

Phone *

Country

(###)

###

####

Home Address *

This needs to be an address we can use for correspondence if required

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you a qualified clinical supervisor or clinical supervisor trainee? *

Qualified Clinical Supervisor

Clinical Supervisor Trainee

Neither/ Not applicable

Please tick which of the following apply *

Please note, we may ask you to submit evidence for the following.

I have up to date/in date insurance

I work in private practice

I have HCPC registration

I work for the NHS

I have ICO registration

I am registered with either the BPS, BACP, NCPS or UKCP

I have completed cultural safety training

I am happy to work with clients that have a faith preference

I am happy to work with clients who are LGBTQ+

I have completed an introduction to safeguarding training

I have completed Level 2 (intermediate) safeguarding training

I have completed Level 3/ Nominated Safeguarding Lead Training

I have completed Level 2 or above in safeguarding children and young people (CYP)

I hereby declare that the information provided is true and accurate to the best of my knowledge. I understand that providing false or deliberately misleading information may result in the rejection of my application or termination of my employment if discovered at a later date. I also understand that providing false or deliberately misleading information may mean I am subject to a disciplinary, formal complaint being lodged against me, revocation from my membership or in some cases, criminal proceedings and police involvement. *

Yes, I declare the information provided is true and to the best of my knowledge