Graduate Diploma In Mental Health (GDMH)
Intake 2016 - 2017
APPLICATION FORM
Please tick the appropriate boxes accordingly. * Delete where applicable
(A)
PERSONAL PARTICULARS
Name (as in NRIC/Passport):
Residential Address
2 passport-sized
photographs
required.
:
Postal Code:
NRIC / Passport Number:
(Please attach a copy of NRIC (front & back) with this application)
Marital Status: Single / Married / Divorced*
Citizenship
Gender: Male / Female*
Clip the SECOND
photograph
together with the
application form.
: Singaporean / Others* (please specify):
Place of Birth :
Date of Birth:
Race :
Paste ONE
photograph in this
space.
Email Address (must be legible) :
Telephone (Home):
Mobile Phone Number:
Name of Next-of-Kin:
Relationship:
Address of Next-of-Kin:
(B)
PRACTICE INFORMATION
MCR Number
:
Medical Registration Type
: Full / Conditional / Temporary*
Type of Practice
Government
NHG
SingHealth
Locum
Private – Group
Private – Solo
:
Hospital / Polyclinic / Clinic Name
Year of SMC Registration:
Others:
:
Hospital / Polyclinic / Clinic Address :
Postal Code
:
Telephone (Office)
:
Please indicate your preferred mailing address with a tick:
Fax (Office)
:
Residential Address
Practice Address
1
(C)
Other Information
Degrees / Diplomas Awarded (Attach a separate sheet if necessary)
Photocopies of the certificates are required
Qualification
Year
Employment History – List all postings since Medical Officer (Attach a separate sheet if necessary)
Position Held
Department in Hospital /
Medical Group / Practice
From
(Month / Year)
To
(Month / Year)
Remarks
(if any)
2
(D)
Mode of Study
Please tick where applicable.
Participants who have attended “Introductory Training to GPs” by IMH will sit for a proficiency test to
determine eligibility for Module 1 exemption.
1. Have you attended “Introductory Training to GPs” (conducted by IMH)?
Yes. (Please proceed to option 2b)
No. (Please proceed to option 2a)
2. I would like to:
st
a.
Apply for full course, payable fee: $6,624.50 (early bird rate for submission to IMH by 31 May 2016)
st
or $6,767.50 (application submitted to IMH from 1 June 2016 onwards)
(Applicant shall pay an exam admin fee of $600 to NUS upon successful enrolment into GDMH. NUS will notify
applicant via email to make this payment online in due course.)
b.
Apply for full course with Module 1 exemption, payable fee:$5,554.50 (early bird rate) or
$5,697.50 (application submitted to IMH from 1st June onwards)
(Applicant shall pay an exam admin fee of $500 to NUS upon successful enrolment into GDMH with exemption
from module 1. NUS will notify applicant via email to make this payment online in due course. Applicants who
select this option are required to pay the payable fee of either $6,624.50 (early bird rate) or $6,767.50
(application received by IMH from 1 June onwards) during registration. Once application for exemption from
Module 1 is approved, a refund of $1,070 will be made.)
Note: MOH sponsors 80% of the course fee (GST inclusive). MOH’s subsidy will be reimbursed to all eligible applicants
upon successful completion of the final exam.
(E)
Declaration
1. I hereby make an application to the Graduate Diploma in Mental Health (GDMH) and declare all information I
have provided on this application form is complete and correct.
2. I acknowledge that my application for enrolment is subject to admission criteria and examination eligibility as
advised by DGMS and IMH, both of which have the power to impose conditions.
3. I agree to participate in the Mental Health GP Partnership Programme upon completing the course.
4. By signing this form, I acknowledge that I have read and agree to abide by the Terms and Conditions stated
under „Important Notes‟.
5. I declare that I am a practicing doctor.
6. I declare that I am free from any legal proceedings, investigation or disciplinary action by the Singapore Medical
Council.
Signature of the Applicant: ___________________________
Date: ___________________
3
(F)
Terms & Conditions
1. The applicant shall adhere to requirements stated in the GDMH Programme Guide.
2. The applicant shall abide by the Non-Disclosure & Security Awareness Agreement.
3. The applicant shall abide by the rules and regulations governing use of IMH premises and library facilities.
4. The applicant shall adhere to guidelines for course work completion, such that all criteria for examination eligibility
are met.
5. The applicant should be free from any legal proceedings, investigation or disciplinary action by the Singapore
Medical Council (SMC). If there are legal proceedings, investigation or disciplinary action pending against the
applicant, this must be informed to IMH.
6. Strictly no refund of fees if there is a notice of withdrawal from GDMH or any of its modules upon course
commencement. A written notice of withdrawal must be submitted for consideration.
7. IMH and/or NUS may, at their discretion, vary terms and conditions governing GDMH at anytime, without notice.
I acknowledge that my enrolment to GDMH is subject to the admission criteria and examination eligibility as advised
by DGMS and IMH, both of whom have the power to impose conditions. I accept enrolment to GDMH and hereby
agree to abide to all Terms and Conditions.
Name
:
MCR number :
Signature
:
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Please send the completed application form (with two photographs attached), a photocopy of the certified true copy
medical degree certificate, photocopy of the certified true copy supporting certifications and a photocopy of your NRIC
(front and back) together with cheque payable to
“Institute of Mental Health”.
Mail to: Buangkok Green Medical Park, 10 Buangkok View Singapore 539747
Attention: Ms Nirhana Japar /Ms Suzanna Gunawi (Education Office)
1) What is/are your objective(s) of studying for the Graduate Diploma in Mental Health (GDMH)?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
2) How did you find out about the Graduate Diploma in Mental Health (GDMH)?
SMA Website
GP Workshop
SMA Newsletter
IMH Website
Mailer Poster
Singapore Medical Journal
NUS Website
Newspaper Article
SMA email blast
MOH Website
Friends
Others: _____________________
IMPORTANT NOTES
1. Fees are applicable as follows:
st
Registration Fee
(non-refundable)
$107 (Early bird rate if application received by IMH by 31 May 2016)
st
$250 (Registration fee received by IMH from 1 June 2016 onwards)
$6,420
Course Fee
(for all 6 modules)
(MOH subsidizes 80% of the course fee. Course fee will be reimbursed to all candidates
upon successful completion of the final exam)
Book Fee
Module 2
$15.50 (“Delusions, Possession or Imagination?”)
Book Fee
Module 5
$82.00 (“A Primer of Child and Adolescent Psychiatry”)
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2. Please ensure that copies of your medical degrees/academic qualifications are stamped „certified true copy‟
before mailing your application. The supporting documents should be stamped certified true copy and signed
by any of the following parties:

Notary public (lawyer)

Issuing university or school and

Head of the Department bearing his official designation, department and signature.
However, if you are submitting your documents in person to IMH, the GDMH administrators will be able to stamp
„Original Sighted‟ and sign on your supporting documents. Please present the original versions for verification
purposes.
3. Deferment
A 10% administrative fee per module ($107 per module) will be payable by candidates who wished to defer any
module. Please be informed that this fee is non-refundable. Candidate is required to inform the GDMH
administrator on the request and fill up the deferment form at least 3 months before the module. The request is
subject to Programme Director‟s approval, on a case-by-case basis.
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GP CLINIC INFORMATION ACCESS CONSENT
There is more awareness and wider acceptance to seek treatment to mental illnesses. The Graduate Diploma in
Mental Health has generated interest among healthcare agencies and public, who are keen in mental health care
providers within the community. Several queries have been made regarding GP clinic information under the
Programme.
We seek your concurrence on the access restrictions for your clinic information. Kindly complete the form and return it
to the GDMH administrators. Please note that your information will be shared with Mental Health & REACH GP
Partnership Programmes with your declaration in Section E (3) in the GDMH application form.
Please complete Section (A) and (B) by ticking against your desired choice.
SECTION (A)
OPTION 1
Go to Section
(B) if selected
I ALLOW general public and private* access to my clinic information
OPTION 2
Go to Section
(B) if selected
I ALLOW ONLY private* access to my clinic information
OPTION 3
I DO NOT ALLOW general public and private* access to my clinic information
* Private access refers to access by healthcare agencies (e.g.VWOs,Family Service Centres, etc)
SECTION (B)
Please select the information that you are agreeable to be listed for access
Name of clinic
Name of Doctor
Clinic Address
Clinic phone and fax number
Email address: _____________________________________ (please state email address)
CDMP/PCPS approved
Name of GP (As in NRIC / Passport)
: __________________________
Signature
: _______________________
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Note:
All fees are quoted inclusive of 7% GST.
NUS & IMH reserve the right to make any amendments to the course structure and fees without any prior notification
or whatsoever to the parties involved.
Refund Policies
Request for withdrawal must be made in writing to the Programme Director. Policies for course fee refund are as
follows:
1. 100% refund if the request for course withdrawal is made in writing more than 30 calendar days before course
commencement.
2. 90% refund if the request for course withdrawal is made in writing no less than 15 calendar days before course
commencement.
3. Strictly no refund of fees if request for course withdrawal is less than 15 calendar days before course
commencement and/or after the course commences.
Note: Calendar days include Saturday and Sunday.
All feedback and correspondences should be addressed to:
Ms Nirhana Japar (Executive, Education Office) | Ms Suzanna (Executive Assistant, Education Office)
Institute of Mental Health
Buangkok Green Medical Park
10 Buangkok View, Singapore 539747
Telephone
: 6389 2831 (Nirhana Japar) | 6389 2239 (Suzanna Gunawi)
Email
: nirhana_japar@imh.com.sg | GDMH@imh.com.sg
Website
: www.imh.com.sg
Fax
: 6389 2834
*
The date is based on the day when IMH receives the letter for withdrawal.
**
Calendar days include Saturday and Sunday.
(H)
For Official Use Only
Fee Paid
: S$______________
Cheque Number
: ________________
Acknowledgement Date
: _________________
Official Receipt Number
: ________________
Checked By
: _________________
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Degrees / Diplomas Awarded (Additional copy)
Qualification
Year
9