Certification Student Trainee Application Form – The Schema Therapy Institute

Schema Therapy Institute

Suite 24 Ground Floor, Hurlingham Studios, Ranelagh Gardens London SW6 3PA

You may add additional pages to this application to clarify or elaborate on any of the questions below, if you need more space.

Your application will not be reviewed unless all questions are answered.

PLEASE INDICATE WHETHER YOU ARE APPLYING FOR INDIVIDUAL, AUXILIARY OR GROUP SCHEMA THERAPY CERTIFICATION BY TICKING ONE OF THE TRAININGS BELOW:

INDIVIDUAL GROUP AUXILIARY

Name

Date

Gender:

Male Female

Current Institution/Organization and Title (if any):

Please Insert a picture of yourself

Work Address

Town / Postal Code

Country

Country Code

Work Telephone

Home Address

Town / Postal Code

Country

Country Code

Home Telephone

Country Code

Mobile Phone

Country Code

Fax

Primary Email Address

Alternate Email Address

Website

If we need to contact you by telephone from 9 am to 4 pm, which number(s) should we use?

Work Phone Home Phone Mobile Phone

Payment Details

I will be personally paying for the training My organisation will be paying for the training

If funded by an organisation/employer, details needed for invoicing

List or describe your reasons for undertaking training in Schema Therapy

Education & Work Experience

All degrees earned

Highest Degree

Year Earned

Field

Please explain the degree(s) you have obtained, and the exact field of study. (Please include how many years of study are invovled)

University (Include city and country)

Describe your Internship(s), Practicum Work, or Residency (including name and location of Institutions)

Describe Graduate Level Training (Post-Graduate Certificate, Masters, Post-Doctoral training)

Professional Accreditation(s) / Licensure / Certification (if required for practice in your field of work)

Membership Number

Professional Body / Country

List previous workshops and training in Schema Therapy, if any (include approximate dates, locations, hours, and instructors)

List the approximate hours per week you currently engage in the following professional activities:

Direct patient contact

Supervise Other Therapists

Administration

Take Courses

Research

Teach / Conduct Training

Other Activities

Other Activities (details)

Current Work Setting / Organisation

Current Position / Title

I currently work with:

(Rate each category on a scale from 0-3 as follows: 0 = not at all, 1 = occasionally, 2 = frequently, 3 = almost always)

Inpatients

Children

Individuals

Outpatients

Adolescents

Couples

IAPT/Partial Hospital Patients

Adults

Families

Criminal Offenders

Geriatrics

Groups

Employment / Work Related Counselling

Domestic Violence Perpetrators

Domestic Violence Victims

Education

Other

Other (details)

Please elaborate on your current professional work, including training, research, administrative and/or clinical activities.

Please elaborate on the nature and amount of clinical training in Schema Therapy you have already received. Include the number of patients you have treated.

During your core training, number of clinical hours under supervision

Please select which training session you'd like to register for

Online In-Person

How did you hear about us?

Contact Permission

Yes, I'd like to hear about future training opportunities No, I don't want to hear about future training opportunities

As well as responding to this enquiry, we'd love to keep you informed of other training courses we run. We'll always treat your personal details with the utmost care and will never sell them to other companies for marketing purposes.

Telephone: 0207 384 9155 Email: training@schemainstitute.co.uk Website: schemainstitute.co.uk

The Schema Therapy Institute, London, and its training programmes were established by the Counselling Pastoral Trust (CPT) in 2009.

The Counselling Pastoral Trust is a Company Limited by Guarantee, founded on 27th August 1993, registered in England and Wales, number: 2848495. CPT is also a Registered Charity number: 1027526. CPT’s Registered Office address is Hurlingham studios, Suite 24, Ground Floor, Ranelagh Gardens London SW6 3PA