Qualification in Clinical Neuropsychology
Reference Request
Information for Candidates
Please ask the referees named in your enrolment form to complete this form. One reference
should relate to your academic studies and the other reference to your practice. At least one
referee must be a Chartered Member of the Society and also appear on the psychology
section of the Health and Care Professions Council’s Register. In both cases original
signatures must be provided. Your Coordinating Supervisor, as named on your supervision
plan, cannot normally be named as referee, nor can a fellow candidate.
Information for Referees
Thank you for agreeing to provide a reference for a candidate applying to enrol for the
Qualification in Clinical Neuropsychology (QiCN). The qualification’s Board is aware that
such requests take time and we appreciate your co-operation. Please provide, in
confidence, your opinion of the applicant’s suitability to enrol as a candidate on the QiCN.
Successful completion of the QiCN confers eligibility to apply for full membership of the
Division of Neuropsychology and entry onto the Society’s Specialist Register of Clinical
Neuropsychologists. If it is helpful to see further details of the qualification and its
requirements please see the following web page: www.bps.org.uk/qicn
In completing the sections below please give particular consideration to the following areas:
A. Professional capabilities, including your knowledge of their current practice.
B. Academic suitability: In your opinion is the candidate able to undertake doctoral level
training successfully?
C. Fitness to practice: Are you aware of any issues that would affect the candidate’s fitness
to practice?
Please note that you can either return your completed reference with the candidate’s
enrolment form or separately to the following address:
The British Psychological Society
St Andrews House
48 Princess Road East
Leicester
LE1 7DR
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Clinical Neuropsychology Qualifications Board
Qualification in Clinical Neuropsychology
Referee’s Name:
Referee’s Membership Number:
(if applicable)
Referee’s HCPC Registration Number:
(if applicable)
Applicant’s Name:
Applicant’s Membership Number:
1.
How long have you known the applicant and in what capacity? If you are/were the
applicant’s employer please give details of their employment with you. If you are/were
the applicant’s academic tutor please give details of their training with you.
FROM: ...................................................
TO: ...........................................................
Comments:
2.
Please give your opinion as to the applicant’s suitability to undertake practice with
clients as part of their enrolment on the Qualification in Clinical Neuropsychology. If you
are/were the applicant’s supervisor please give details.
EXCELLENT

GOOD

SATISFACTORY

POOR

Comments:
3.
Please give your opinion as to applicant’s academic suitability to successfully complete
training on the Qualification in Clinical Neuropsychology.
EXCELLENT

GOOD

SATISFACTORY

POOR

Comments:
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4.
Please comment on the applicant’s ability to work with others, including clients,
colleagues and line managers.
EXCELLENT


GOOD
SATISFACTORY

POOR

Comments:
5.
Please comment on any fitness to practice issues you are aware of that might be
relevant to the applicant’s ability to work safely with clients as part of their enrolment
on the Qualification in Clinical Neuropsychology.
Comments:
6.
Any other comments you would like to make
Referee name: .........................................................................................................................
Referee signature: ...................................................................................................................
Position: ...................................................................................................................................
Date: .......................................................................................................................................
The person about whom this reference is given may have right under the Data Protection Act
1998 to require us to disclose the reference about him/her subject to the identity of the
person named below being protected. You may choose to waive your right to anonymity. If
you (the referee) are willing to waive your right to anonymity in the event of us having to
disclose this reference, please tick the box.
YES

NO

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