Associate Therapist
Registration Form
The mission of CBT Services Ltd is to assist our clients back to normal
functioning whilst ensuring ethical practice by protecting both clients and
Associate Therapists alike.
CBT Services would appreciate it if you could provide us with the following information
for our own records and to help us give the best service possible to our client’s.
1. THERAPIST’S DETAILS
Title:
First Name
Surname:
Correspondence Address:
Postcode:
Contact Numbers:
Primary:
Secondary:
E-mail:
Website:
Fax:
Accredited by:
Accreditation Number:
Indemnity Insurance Insurer:
CRB check: (Y/N)
Date Issued:
Level of Indemnity:
Disclosure Number:
Date Issued:
Languages Spoken:
CBT Services Ltd
Edison House, Hadley Park, Telford, TF1 6QJ
CBT Services Ltd / Version 3.2 09.13 / 25.09.13
1
2. ASSESSMENT & TREATMENT DETAILS
Clinic:
Do you have a clinic: Yes / No
(if yes, please provide address below)
Days / times Out Of
Disabled
Clinic Address: (Please advise if clinic
at
clinic:
Hours:
(i.e
access:
is residential)
(i.e Mon,
Tues a/m.)
evenings /
weekends)
Home Visits:
Do you do home visits: Yes / No
Distance willing to travel for: Assessment:
Mileage cost:
Parking:
Y/N
Y/N
Treatment:
(hourly rate / pence per mile)
Costs: Overall set fees inclusive of relevant reports & paperwork.
Assessment (Home visits):
£
(inclusive of full report) + mileage cost
Assessment (Clinic):
£
(inclusive of full report)
Treatment (Home Visit):
£
(inclusive of feedback after every 6 sessions)
Treatment (Clinic):
£
(inclusive of feedback after every 6 sessions)
Areas of Experience / Specialism:
Qualifications:
i.e. addictions, anxiety, CFS, depression, OCD, pain, panic, PTSD etc
Qualified to work with (please delete those not relevant to you):
*Adults (18+) *Adolescents (13-18) *Children (up to 12 yrs) *Elderly (60+)
*Individuals *Couples *Families *Groups
Other:
CBT Services Ltd
Edison House, Hadley Park, Telford, TF1 6QJ
CBT Services Ltd / Version 3.2 09.13 / 25.09.13
2