Accreditation Procedure Stage 1 - Application Form

Name: 	
	
Address: 

Daytime Telephone:

Mobile:

E-mail:		

Date of birth:

Occupation: 

University degrees (if applicable) with dates of completion:  

Other professional qualifications, with dates: 

Membership of Professional Associations: 

Please write about the following, with careful reference to the stated criteria for accreditation: 

1.	Psychotherapy Training. Please describe your training experience, including the structure and components of your training. If you have not followed a formal course, describe your portfolio of training experiences. Please refer to the CPJA document ‘Standards of Education and Training’ listed along with the other Accreditation documents on the WMIP website. Copies of qualification certificates should be included with your application as supplementary pages.

2.  Personal Psychotherapy. Please give details including the name of your therapist(s), dates and frequency of sessions. 

3.  Supervised clinical practice. Please give details including dates and frequency of sessions. 

4.  Mental Health Experience 

5.  Ongoing Professional Trainings/Courses 

6.  Any other information that you would like us to take into consideration 

7. A declaration of any complaints where feedback was received over the last      
    five years. Complaints that have not been upheld should not be included.

I enclose my cheque for £35 made payable to WMIP and confirm that the information I have provided is correct. 

Signed 						Date    

If you want to print and complete this form as a hard copy, please return the form and any supporting documents to:

The Administrator, WMIP, 
66 Smirrells Road, 
Hall Green,
Birmingham 
B28 0LB.