STAFFORDSHIRE UNIVERSITY
POST GRADUATE DIPLOMA IN CBT
APPLICATION FORM
ADDITIONAL INFORMATION
Name...........................................
Address.................................
..........................................
Daytime telephone number......................
E-mail address.................
1) Please give details of any previous training in CBT
2) Please give experience of any previous experience of using CBT
3) Please indicate why you have decided to apply for this course
4) Please give details of your current workplace and your ability to access clinical
work with clients with common mental health difficulties such as anxiety or
depression. Please indicate whether you anticipate having access to clinical
supervision with a supervisor who has significant experience in using CBT
5) The support of your manager is essential to enable you to undertake this
award: Please ask your manager to complete the section below.
Name of manager.......................
Contact telephone number...............................
E-mail address.......................................................
To successfully complete the Post Graduate Diploma in CBT your member of staff will
need to undertake the following:
Attendance at Staffordshire University for 2 teaching days per week from
January 2013 to December 2013

Accrue 200 hours of face to face clinical work with adult clients with common
mental health difficulties such as anxiety or depression

Accrue 70 hours of clinical supervision with a BABCP accredited supervisor

Complete a range of academic assignments – we recommend that trainees
should have 3.5 hours of study leave per week
Please sign below to confirm that you are aware of and will support your member of
staff in fulfilling these requirements:-
Signature of manager...............................................
Date.................................................
Signature of applicant........................
Date................................................................