Caspari Foundation

Advanced Diploma in Educational Psychotherapy /

Certificate in Therapeutic Teaching application form

Please indicate with X which course you are applying for / X
Advanced Diploma in Educational Psychotherapy
Certificate in Therapeutic Teaching
Personal details
Title and full name / Home address
Date of birth: / Ethnicity:
Do you consider yourself to have a disability / additional needs? YES / NO
If yes, please outline:
Telephone numbers Daytime : Evening:
Email address:
Current role and length of time in post: / Work address:
Educational Qualifications. Please list most recent first.
University / School / College – Name and Address / Qualification achieved / Grade / Subjects / Date started and date awarded.
Please list any other relevant professional qualifications or CPD.
Employment History. Please list most recent first.
Employer’s name and address / Dates from and to / Position held / Brief outline of duties
How did you hear about this course?
Will your present commitments allow you sufficient time to do the course?
1styear : 1 evening a week , 6.20-9.00, 2 Saturdays – 10.00 – 4.00 and 1 x 50 minute a week personal psychotherapy session (Adv Dip only).
2nd & 3rdyear : As above, plus 1 day a week on clinic placement, 1 x 50 minute supervision session & 1 hour a week spent observing a baby / nursery aged child. Time for write ups should be considered.
4th year: Approx. 2 evenings per half term attendance on course, clinic placement and supervision continues if required.
Personal Statement:
Please be as thorough as possible in your answer and include:
Why do you consider this course a good match for you?
-How have your own experiences of growing up, family life, your own education and any other experiences influenced your interest in working with children and young people whose educational, social and emotional wellbeing has been adversely affected by their life experiences?
-How you think the course will be relevant to your current role?
Please tick to indicate you have read and understood. /
I wish to apply for the 4 year part-time Advanced Diploma in Educational Psychotherapyor
1 year part-time Certificate in Therapeutic Teaching course.
I confirm that I have not * been dismissed from employment or any other type of work with children nor have I been refused membership of a professional body or register on the grounds of professional misconduct in the UK or abroad.
* If this is not the case please provide an explanation
I understand that if I am invited for interview I will be required to bring:
-An enhanced DBS certificate which is not less than 3 years old
- Original certificates of my qualifications
- Details of most recent Safeguarding training ; date, place obtained and level if
relevant
- Proof of address and photo ID

Name:

Signature:

Date:

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Caspari Office use only

Interview offered: Yes / No

Explanation for above decision:

Interview date and time:

Interview panel:

Lynsey Daniels

Programme Leader

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