Application to Register with the Complementary & Natural Healthcare Council (CNHC) Name of professional association International Cranial Association (ICRA) ICrA Membership Number (your name) Email address Date of birth I give permission for you to check my details and then confirm my eligibility to CNHC for the purposes of entry to the CNHC Register in the following disciplines: (please tick) Craniosacral Therapy Name Signed Date Please return your completed form BELOW direct to ICrA which will verify your registration. When ICrA has processed your form they will send it to CNHC for you. You will then be sent an automatic email from the CNHC inviting you to complete your registration online. The CNHC registration fee is £60 for your first discipline. Each additional discipline costs £10 up to your 4th discipline, after which there is no fee for additional disciplines. If you do not have an email address you can apply offline. Once ICrA has verified your application CNHC will send you postal information to complete and return to them to process. Please be advised that there will be a £10 administration fee for those who wish to apply offline as CNHC will need to manually process your application. Registrants will then receive a hard copy registration certificate via post. CNHC contact : Tel: 020 3178 2199 / Email: info@cnhc.org.uk / Website: www.cnhc.org.uk 1 Application for Verification NOTE: Applicants are required to have professional indemnity insurance Practice details PERSONAL DETAILS Title: Gender: Surname: Forename/s: Contact Address: (Inc postcode) Home Telephone: Work Telephone: Mobile Email address: PRACTICE WEB SITE ADDRESS I confirm that I have Professional Indemnity Insurance Company: Policy number: Expiry date: THERAPIES COVERED LEVEL OF COVER (£) Your practice Practice address Please describe your current practice arrangements Number of other practitioners Number of patients you see per week 2 Hours per week worked Therapies you offer and % of time/ numbers on each Qualifications NOTE: if you qualified in craniosacral therapy after 1997 at one of the Colleges that have been validated against the National Occupation Standards for Craniosacral therapy, your application can be fast tracked. (see CNHC web site for details). If you cannot be fast tracked, your application will be assessed on both training and experience (APEL). We need to know about ALL your healthcare training, your practice history, and other registered therapies. As a guide, the requirements are that you have been in continuous practice for at least 3 years AND have training in anatomy and physiology AND have completed 30 days cranial therapy training. The minimum is 10 days training plus 7 years in practice. Three Case Studies are also required (guidance on last page) if you are NOT a Statutory Regulated health professional such as osteopath, chiropractor, nurse or HPC-registered profession. NOTE If your training was through shadowing and mentoring rather than formal taught courses, please describe in full giving hours and nature of training, on extra pages OFFICE USE ONLY COLLEGE COURSE TITLE AWARD/ DEGREE NUMBER OF TAUGHT DAYS COMPLETION DATE VERIFIED/ NOT VERIFIED/ NOT APPLICABLE PLEASE NOTE THAT WE MUST HAVE PROOF OF ALL QUALIFICATIONS HELD. PLEASE ATTACH A COPY OF QUALIFICATION CERTIFICATE(S). (PLEASE DO NOT SEND ORIGINALS AS THESE CANNOT BE RETURNED) 3 Continuing Professional Development The CNHC requires at least 15 hours of CPD annually of which at least 10 hours must be specific to cranial therapy. See the CNHC web site for activities which count towards CPD http://www.cnhc.org.uk/index.cfm?page_id=29 DATE Please list ALL CPD undertaken in past 5 years. Use up to 2 additional sheets RELEVANT COURSE TOPIC ORGANISATION HOURS/ DAYS OF TO CRANIAL CPD THERAPY? 4 Safety and professional standing MEMBERSHIP OF PROFESSIONAL ORGANISATIONS AND REGISTERS ORGANISATION MEMBERSHIP NUMBER Specifics Have you been in continuous practice as a cranial therapist for the past 7 years? If not please specify how many years Have you ever had a complaint against you or your practice from a member of the public? If yes, please specify Have you ever been convicted of any criminal or civil offence (apart from speeding)? If yes, give details and penalty imposed. YES NO YES NO YES NO Please give date of your current CRB certificate? If you do not have one, please state reason YES NO Please give date of you current First Aid certificate? If you do not have one, please state reason YES NO Which private health insurers are you recognised by? please state which ones YES NO Do any Health practitioners refer patients to you? If yes, give main sources Do you refer patients to other health care practitioners for further treatment of investigation? If so, give main routes of referral YES NO YES NO 5 Character Reference Form A reference as to the applicant’s character is to be provided on this form by a person of professional standing in the community, who is not a relative and who has known the applicant for at least 3 years. The referee must know the applicant well enough to make a judgement as to the applicant’s integrity, trustworthiness and honesty. People of professional standing include JPs, lawyers, accountants, health care professionals, religious officials or senior figures in business, the public sector or voluntary sector. Name of Applicant Address The above person has applied to join the Register of CNHC, the voluntary regulatory body for complementary health practitioners. In order to be eligible to be admitted to the Register, the applicant must satisfy CNHC that he/she is of good character. Referee’s Name Occupation Practice or Business Contact Address Telephone Number and Email address Please state in what capacity the applicant is known to you: Please complete as appropriate I am satisfied that, to the best of my knowledge, the applicant is of good character and fit for registration (please tick) YES If NO above: the CNHC should be aware of the following details of the applicant’s character, which might affect his/her suitability for registration (continue overleaf if required) Date: Signed: For any queries or help completing this form, please email info@cnhc.org.uk or call CNHC on 02031 782199 6 NO Three Case Studies These are ONLY required for applications from practitioners who are NOT Statutory Regulated. The guidance for case studies is currently based on that developed by BANT for Nutritional Therapy, which can be accessed from these links. http://www.bant.org.uk/bant/pdf/nonBANTCNHC/EXTERNAL_FULL_PORTFOLIO_CASE_S TUDY_INSTRUCTIONS.pdf http://www.bant.org.uk/bant/pdf/nonBANTCNHC/EXTERNAL_FULL_PORTFOLIO_EXAMP LE_CASE_STUDY.pdf Please follow the BANT guidelines as applicable to your cranial therapy practice and submit the case studies with your application. 7