IN COLLABORATION WITH
FACULTY OF SOCIAL SCIENCE AND HEALTH CARE

A.
OGNITIVE
EHAVIOURAL
HERAPY
PERSONAL DETAILS
Name ........................................................................ Title ...........................
Occupation .............................................................................................................
Home Address .......................................... Work Address ...........................................
................................................................... ...................................................................
................................................................... ...................................................................
Tel. ............................................................ Tel. . ...................................................
Mobile: ……………………………………….
Email :………………………………………….
Email:…………………………………………. Date of Birth: …………………………………
Which is your preferred address and telephone number for contact? Home Work
B. ACADEMIC QUALIFICATIONS*
Subject Qualification Institution Date
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C. PROFESSIONAL QUALIFICATIONS *
Subject Qualification Institution
D.
* In chronological order.
EMPLOYMENT HISTORY * (including current position)
Position Employer
* In chronological order.
E. DESCRIPTION OF CURRENT PROFESSIONAL RESPONSIBILITIES
1.
In which setting do you work (hospital, GP surgery, community etc.)?
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Date
3
Dates

2.
3.
F.
2.
Do you manage your own caseload and would you have ready access to patients suitable for CBT (5 cases during the course)? Where do you plan to get your patients from?
3.
Apart from Cognitive Therapy cases, what other type of clinical work do you engage in?
4.
Please give a brief description of the nature and degree of clinical responsibility in your current clinical work.
1.
RELEVANT COGNITIVE B EHAVIOURAL THERAPY EXPERIENCE (including supervision)
With how many patients has Cognitive Behavioural Therapy influenced your clinical practice in the last 2 years?
What type of cases?
Which models of Cognitive Behavioural Therapy influence your clinical work?
(Please name specific theorists.)
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4. Please list seminars, professional meetings, conferences and training courses you have attended relevant to Cognitive Behavioural Therapy?
5. Please list books and/or articles on Cognitive Behavioural Therapy you have found useful.
7.
8.
Please describe any research experience/interest in Cognitive Therapy.
Please list any memberships of Societies, Special Interest Groups, Journal
Subscriptions etc. relevant to Cognitive Therapy.
G.
9.
1.
2.
Please give any further relevant information.
THIS APPLICATION
Please state your main reason for applying for this course.
What do you hope to get from this course?
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H.
SHORT ESSAY. Please respond to the essay question below. Approximately 1,000 words is sufficient. You can use a separate piece of paper for this, but we ask that it is typed. Please put your name at the top of the sheet in case it becomes detached from the rest of the application form.
“Describe a case that you have worked with recently in which CBT influenced your practice.”
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I. ( TO BE COMPLETED BY LINE MANAGER
Line Manager’s Name
) S UPPORT
Address ....................................................
...................................................................
...................................................................
Email ………………………………………….
Phone: ……………………………………….
1. Access to Clients
The SoS CBT training course requires that trainees have access to at least 5 training cases of mild to moderate anxiety and depression. Can you confirm that the trainee will have access to appropriate patients through your service or suggest where they may obtain such cases?
2. Line Manager Statement of Support:
I fully support this application. Should this applicant be successful, (s)he will have protected CBT time of a minimum of one day per week for the duration of the course and that only appropriate cases will be used for training purposes.
SIGNATURE OF LINE MANAGER ……………………………. DATE………………...
Please return completed application forms to :- Ibbie Shearer, CBT Course Administrator, CBT
Administration Office, Psychology Dept.,, 2 nd Floor Mackinnon House, Royal Edinburgh Hospital,
Tipperlinn Road, Edinburgh EH10 5HF.
Please also email a copy to: Elizabeth.shearer@nhslothian.scot.nhs.uk
N.B.
C
IS T
18 F
2016.
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REFERENCE
PLEASE ASK A REFEREE (NOT YOUR CURRENT LINE MANAGER) TO COMPLETE
AND RETURN THE ATTACHED REFERENCE TEMPLATE TO US BY EMAIL BY 18
FEBRUARY 2016.
NB. YOU WILL NOT BE CONSIDERED FOR INTERVIEW UNLESS WE HAVE RECEIVED
YOUR REFERENCE BEFORE YOUR INTERVIEW DATE.
YOUR REFEREE MUST BE ABLE TO COMMENT ON YOUR PROFESSIONAL
PRACTICE AND SUITABILITY FOR EMBARKING ON POSTGRADUATE
TRAINING IN CBT.
Email to: elizabeth.shearer@nhslothian.scot.nhs.uk
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REFERENCE FOR ………………………………………………………… (NAME)
(in confidence)
1.
Please comment on the applicant’s academic ability to embark on a postgraduate course of study.
2.
In your view, does the applicant demonstrate good core skills that would allow her/him to develop as a CBT therapist eg. the ability to form a therapeutic relationship, capacity to reflect critically on her/his practice, respond to critical feedback.
3. How long have your known the candidate and in what capacity?
Signed ……………………………………………………………………………….
Job Title …………………………………………………….. Tel. No. …………………….
E mail ………………………………………………….
Please email this form to : elizabeth.shearer@nhslothian.scot.nhs.uk
by 18 February 2016
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