BACPUKCPNCSCOSRTBPSBABCPOther
If other please specify
Membership Number
Code of Ethics to which you adhere
Adult individuals (18+)CouplesFamiliesAdolescents (age 13-17)Young children (up to age 5)Older children (age 5 - 12)Other
Post-qualification client hours to date
BUPAAXA/PPPCignaAvivaEmployee Assistance Program(s)OtherNone
Mon
Morning 9 - 12
Afternoon 13 - 16
Evening 17 - onwards
MonMon: Morning 9 - 12Mon: Afternoon 13 - 16Mon: Evening 17 - onwards
TueTue: Morning 9 - 12Tue: Afternoon 13 - 16Tue: Evening 17 - onwards
WedWed: Morning 9 - 12Wed: Afternoon 13 - 16Wed: Evening 17 - onwards
ThuThu: Morning 9 - 12Thu: Afternoon 13 - 16Thu: Evening 17 - onwards
FriFri: Morning 9 - 12Fri: Afternoon 13 - 16Fri: Evening 17 - onwards
SatSat: Morning 9 - 12Sat: Afternoon 13 - 16Sat: Evening 17 - onwards
SunSun: Morning 9 - 12Sun: Afternoon 13 - 16Sun: Evening 17 - onwards
First Name
Last Name
Address
City
State / Province / Region
Post Code
Country AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua & DepsArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia HerzegovinaBotswanaBrazilBruneiBulgariaBurkinaBurundiCambodiaCameroonCanadaCape VerdeCentral African RepChadChileChinaColombiaComorosCongoCongo {Democratic Rep}Costa RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIreland {Republic}IsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmar, {Burma}NamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussian FederationRwandaSt Kitts & NevisSt LuciaSaint Vincent & the GrenadinesSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe
Email
Phone Number
Website
Qualifications WITH completion dates AND training organisation
Clincal orientation (psychodynamic, integrative, etc.)
Areas of specialisation
Have you ever had a professional complaint upheld against you or been asked to leave a place of work? If yes please provide details
Hours of supervision you have each month?
Supervisor’s name
Are you able to offer at least 10 hours a week (incl at least 1 evening) at Mind Garden? YesNo
Supervisor’s email address
Please describe your current work commitments elsewhere
Why do you want to work at Mind Garden?
Hours of supervision you have each month? YesNoNot sure
How do you plan to build your practice?
Working at Mind Garden requires regular use of an online room booking system, online calendar, and email communication. Please indicate your level of confidence in being able to independently utilise these facilities. Very confidentSomewhat condfidentNot confident
Are you currently in personal therapy? YesNo
Total hours of personal therapy
How did you hear about Mind Garden?
Please upload your latest CV
