APPICATI FR n INREASIN ORORE AE INCREASING WORKFORCE … · (including Enhanced Disclosure Certificate for clinicians that wish to work with children less than 16 years of age). Applicants

INCREASING WORKFORCE VALUE

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APPLICATION FORMAffiliate Clinician

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Personal Details

Professional Details

Professional Qualifications

Full Name:

Home Telephone:

Work Telephone:

Home Address:

Date of Birth:

Personal email:

Any Contact Pref?

I like to be identified professionally as a

Please describe your current theoretical approach:

Mobile Number:

Business Email:

Other languages?

Number of Years in practice:

From time to time, clients request a clinician of a particular ethnicity or religion. Please provide any information you would be happy for us to hold on these areas:

Note: Please attach/scan copies of certificates for any qual fications stated

Religion: Ethnicity:

Please describe any experience, past or current, working with Employee Assistance Providers (EAPs):

Qualificatio Accrediting Body Clinical Approach Training Duration

IMPORTANT! The Application Form includes fillable field capabilities and latest version of Acrobat Reader will be required in order to successfully complete this form. Available here for free: https://get.adobe.com/uk/reader/ We recommend that you open the Acrobat Reader program, click on file/open and locate the form saved on your computer hard drive. Then fill out the form by typing in the form’s displayed fields, using Acrobat Reader, independently from your browser or your Internet connection. Please email this form and relevant documents to: [email protected]

Alternatively, please print the application form, complete by hand, scan and send to the above email address.


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APPLICATION FORMAffiliate Cliniciannnn

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Clinical Practice Specialisms

Supervision Arrangements

Additional information required to apply to the Validium Psychological Services Team

YES NO

YES NO

YES NO

Do you conform to the requirements of your professional training organisation with regards to supervision requirements?

Please describe ongoing supervision arrangements:

Contact Number: Name of Supervisor:

Please describe any training/experience you may have in providing psychological rehabilitation/return to work and fitness forwork interventions:

Are you BABCP accredited?

Are you HCPC Registered? YES NO

If ‘Yes’, Number:

Are you on the expert witness register?

YES NOAre you qualified to use psychometric testing?

If ‘Yes’, which measures/metrics do you use?

Clinical Specialism (e.g. drugs/alcohol, couples, stress management, major depression, family issues etc.)

Supporting Evidence (e.g. qualifications, training, clinicalexperience)


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Additional information required to apply to the Validium Trauma and Resilience Team

Details of your counselling/psychotherapy/psychology premises

Please list any experience in Psychological First Aid / Critical Response Work:

Please list any training in Psychological First Aid / Critical Response Work:

Business Address: Type of Premises:

Please briefly describeyour premises, e.g. space, noise, heating, lighting and furnishing:

Access to toilet/handwashing: Privacy from being overheard:YES NO YES NO

YES NO YES NO

Please describe your personal security (in case of abusive client):

Security arrangements for client notes/records:

Do you consider that your premises has disabled access for counselling purposes?

Is it possible to enter, move around the building and access the toilet without climbing steps?

Access Information:

Access to Public Transport: Parking for Private Transport:

Please provide access instructions for clients:

If you have additional practice addresses, please enter them on the final blank page


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Insurance Cover (Validium require a minimum of £3 million cover)

Further Details

Coverage per incident:

Policy Number: Insurer:

Have you been DBS checked? (Please provide a copy of a valid certificateIf ‘Yes’, to which level?

YES NO

I understand that submission of this information does not constitute approval or acceptance in The Validium Group Affiliate Clinician Network and grants me no rights or privileges in this Network until such time as I receive notice of participation.

NB: Signing this form indicates your agreement for us to hold this information on our secure database in both electronic and written formats.

Signed: Date:

Please email this form and relevant documents to:

Thank you for your application to become a Validium affiliate.

You will receive further information about how to proceed when the application has been processed and evaluated.

IMPORTANT NOTE:Please remember to enclose copies of Practising/Accreditation/Registration Certificate, Professional Insurance, CV, relevant diplomas and degrees and any other supporting documents (including Enhanced Disclosure Certificate for clinicians that wish to work with children less than 16 years of age). Applicants are asked to provide their passport at interview stage.

Save form

Print form

[email protected]

Validium operates a secure communication platform and will no longer accept information by post. Please therefore submit this application by email in the first instance.

The Application Form includes fillable field capabilities and latest version of Acrobat Reader will be required in order to successfully complete this form. Available here for free: https://get.adobe.com/uk/reader/ We recommend that you open the Acrobat Reader program, click on file/open and locate the form saved on your computer hard drive. Then fill out the form by typing in the form’s displayed fields, using Acrobat Reader, independently from your browser or your Internet connection. Alternatively, please print the application form, complete by hand, scan and send to the above email address.


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Please use this page to provide any additional information

Documents

APPICATI FR n INREASIN ORORE AE INCREASING WORKFORCE … · (including Enhanced Disclosure Certificate for clinicians that wish to work with children less than 16 years of age). Applicants