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The Institute of Group Analysis, 1 Daleham Gardens, London NW3 5BY
Tel: 020 7431 2693, E-Mail:
APPLICATION FOR COURSES LEADING TO MEMBERSHIP OF THE INSTITUTE OF GROUP ANALYSIS
Application for the Manchester IGA Qualifying Course in Group Analysis
2018
PERSONAL DETAILS
Surname:
First Names:
Address:
Date of birth:
Telephone number (work):(mobile):
(home):
e-mail:
Please provide contact details for 2 referees who know you in a professional capacity
Referee 1.
Name:
Position:
Contact number:
Contact email:
Referee 2.
Name:
Position:
Contact number:
Contact email:
Date Foundation Course (previously Introductory Course) completed:
If this is less than 5 years ago please give the name of your small group conductor, who will be asked for a brief report if the IGA does not already hold one.
Small Group Conductor:
If you completed the course more than 5 years ago please provide contact details for someone who is familiar with how you conduct yourself in a group setting.
Referee 3:
Name:
Position:
Contact number:
Contact email:
Date Post Graduate Certificate/Diploma Course passed:
Name of Work Reflection Group Supervisor:
Did you obtain Group Work Practitioner Status, (please give year/course centre)?
Training Group Analyst
The TGA will be asked to provide confirmation of your commencement in a twice-weekly group but does not submit a report.
Name:
Days and times of group meetings:
Length of time in therapy:
Previous therapy
Please give details of any previous experience of personal therapy in a group or individual prior to joining your twice weekly group with a training group analyst. Please include orientation of therapist, duration and frequency of therapy:
EMPLOYMENT HISTORY
Job Title (Give brief outline of duties) / Name and address of employer / From / To / Please give details of employment (paid or unpaid) over the last 10 years - give most recent first, including brief details of duties.If you wish to include a CV to amplify any of this information please do so.
EDUCATION AND TRAINING
Secondary School / From / To / Subjects Passed / Level /Grade / Year ObtainedUniversity/College/
Institute / From / To / Qualification/Courses / Year Obtained / Please continue on a separate sheet if necessary.
Please include internal and external courses.
HEALTH
Please describe any health problems or disabilities you feel may be relevant / Disability or health problems do not preclude full consideration for the Course.
PSYCHIATRICEXPERIENCE
Please give details of your previous experience in a psychiatric setting (including as an observer)
Position held:
Name of institution:
Duration: From:To:
PERSONAL STATEMENT
What has influenced your wish to train as a Group Analyst?
Please include relevant details of family history, personal and professional development, and current and past life events.
(Expand this section as necessary or attach a separate sheet)
DECLARATION
I declare that the information given on this form is true and complete.
Signature/Name:Date:
Pleaseemail this application form to Bethan Marreiros, Management Administrator, by 31stJanuary. Your selection fee of
£495 is to be paid once confirmation of receipt of application is received.
The Institute of Group Analysis aims at equal opportunities in its organisation, practice and teaching
All information provided by applicant will be treated as confidential