Email:ebsite:
ApplicationFormforTraining
SchemaTherapyInstitute,TheCourtyard,FulhamPalace,BishopsAvenue,LondonSW66EA
Youmayaddadditionalpagestothisapplicationtoclarifyorelaborateonanyofthequestionsbelow,ifyouneedmorespace.
Name______Date______Gender: Male☐ Female ☐
CurrentInstitution/OrganisationandTitle(ifany):
______
______WorkAddress:______Town/PostalCode:
______
Country:
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Home Address: ______
Town/PostalCode:
______
Country:
______
*Work Telephone: ______
*Home Telephone: ______Mobil Phone: ______*Fax: ______Primary E-Mail (required): ______
AlternateE-Mailaddress(optional): ______Website (optional):______
*Besuretoincludeyourcountrycode,andcitycode.
Ifweneedtocontactyoubytelephonefrom9amto4pm,whichnumber(s)shouldweuse?
WorkPhone☐HomePhone☐MobilePhone☐
EducationWorkExperience
HighestDegree:
______Year Earned:______Field: ______
Pleaseexplainthedegree(s)youhaveobtained,andtheexactfieldofstudy.(Pleaseincludehowmanyyearsofstudyareinvolved)
______
______
______University(includecityandcountry): ______
______DescribeyourInternship(s),PracticumWork,orResidency(includingnameandlocationofInstitutions):
______
______
______DescribeGraduateLevelTraining(Post-GraduateCertificate,Masters,Post-Doctoraltraining):
______
______
ProfessionalAccreditation(s)/Licensure/Certification,(ifrequiredforpracticein your field of work).
______
______Professional Body / Country: ______
ListpreviousworkshopsandtraininginSchemaTherapy,ifany(includeapproximatedates,locations,hours,andinstructors)
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CLIENT WORK EXPERIENCE
Listtheapproximatehoursperweekyoucurrentlyengageinthefollowingprofessionalactivities:
______Directpatientcontact______SuperviseOtherTherapists
______Administration
______Takecourses;study
______Research______Otheractivities(pleasespecify):______
______Teach/ConductTraining______Main work setting/organisation: ______
Current Position/Title:
______
Icurrentlyworkwith:
(Rateeachcategoryonascalefrom0-3asfollows:0=notatall,1=occasionally,2=frequently,3=almostalways)
____Inpatients____Children
____Individuals
____Outpatients____Adolescents____Couples
____IAPT/PartialHospitalPatients____Adults____Families
____Criminaloffenders____Geriatrics____Groups
____DomesticViolence____DomesticViolenceVictimsPerpetrators
____Education____Employment/WorkRelatedCounselling
____ Other (please specify):______
Youmayaddadditionalpagesifnecessarytoanswerthefollowingquestions:
1.Pleaseelaborateonyourcurrentprofessionalwork,includingtraining,research,administrativeand/orclinicalactivities.
2.PleaseelaborateonthenatureandamountofclinicaltraininginSchemaTherapyyouhavealreadyreceived. Includethenumberofpatientsyouhavetreated.
3.Pleaseelaborateonyourgeneralclinicaltrainingandpreviousclinicalexperience.
4.DuringthecourseofthistrainingIcansubmitaudioorvideorecordingsofactualpatientsessions:1. YES______2. NO______3.UNCERTAIN______
IfyouansweredNOorUNCERTAINtoquestionAabove,pleaseprovide areasonbelow:
______
______
5.Isthereanyotherinformationaboutyouthatwouldbehelpfultousinevaluatingyourapplication?
6.References:
a)Professional:In the space belowlistatleastoneprofessionalwhohassupervisedorobservedyourclinicalworkwithpatients.(Theclinicalworkdoesnothavetoinvolveschematherapy.)
Pleaserequestyourrefereestowritealetterofreferenceandsenddirectlyto:AdmissionsSchemaTherapyInstitute,
CPT,TheCourtyard,FulhamPalace,BishopsAvenue,LondonSW66EA
Professional/Clinical Reference:
Name:______Position:______Address: ______
______Phone: ______Fax: ______E-mail: ______
Personal Reference:
Name:______Relationshiptoyou:______Address: ______
______Phone: ______Fax: ______E-mail: ______
Youcansendusyourcompletedapplicationbyemail(asaWordattachment);andbypost.Our contactinformationis:
SchemaTherapyInstitute
CPT,TheCourtyard,FulhamPalace,BishopsAvenue,LondonSW66EA,UnitedKingdom
Telephone:02073849155
Email:bsite: