Application Form 2015-16
PART II OF THE APPLICATION PROCESS
Please return one electronic copy to Alison Burt, cpadmin@tavi-port.nhs.uk and one
paper copy to Alison Burt, DET, M80 Course Administrator, Tavistock and Portman
NHS Foundation Trust, 120 Belsize Lane, LONDON NW3 5BA
Closing date for applications is: 23 January 2015
M7 INFANT OBSERVAION COURSE AND COURSEWORK
- Name and address of where you studied observation course
- Date of completion (if currently studying please state when you expect to complete)
- Observation Course M7 References
We collect references from your M7 tutors in each case please state name, address, email and contact number for
each:
M7 TUTOR
NAME
EMAIL
ADDRESS
PHONE
NUMBER
WORK DISCUSSION
INFANT
OBSERVATION
YOUNG CHILD
M7 COURSEWORK ESSAYS
You are required to submit 4 essays in total along with this application form, if all 4 papers are ready. However if
they are being prepared for submission this year you can submit 3 papers with your application and delay submission
of one of Infant Observation Paper or Work Discussion Paper by a date to be confirmed at interview. Please indicate
below on the left which are included and which is to follow.
PAPER
please indicate either;
YES INCLUDED or DATE WHEN EXPECTED
INFANT OBSERVATION PAPER
WORK DISCUSSION PAPER
CHILD DEVELOPMENT RESEARCH ESSAY
ONE PSYCHOANALYTIC THEORY ESSAY
3. Personal Analysis/Psychotherapy
- Are you at present having personal analysis/psychotherapy
Yes
No
- No. of Sessions per week
Please give the name and address of analyst
Eligibility For ACP Registration: ACP Student Registration Form A
Association of Child Psychotherapists Student Registration 2014-15
The information below is required by the Membership Committee of the ACP, in order to ensure that
potential trainees meet the requirements for training.
Please complete each section fully and carefully. Incomplete information may result in delays in a
decision being made. Please include under Academic Qualifications any course you are currently
enrolled on and when due to finish.
Association of Child Psychotherapists Student Registration 2015
The ACP is the registering body for Child Psychotherapy in the UK. Student membership of the ACP
is a requirement for starting your post as a trainee child psychotherapist.
The information below is required by the Training Council of the ACP, in order to ensure that
potential trainees meet the requirements for training.
Please complete each section fully and carefully. Incomplete information may result in delays in a
decision being made. Please include under Academic Qualifications any course you are currently
enrolled on and when due to finish, including your preclinical training.
Name:
Address:
Training School:
Degree/
Diploma
etc
Subject
Date
Awarding
Institution
Academic Qualifications:
Qualification
Professional Qualifications
(if any):
Date
Awarding Body
Class
Experience of work with children and adolescents
List most recent first.
Please ensure you show and distinguish clearly how much time has been spent working with
under-fives, latency children and adolescents. If your job covers a range of ages, please indicate
roughly what proportion of your time is spent with each age group
Full or
Age of
Dates
Institution
Role
Part time
children/adolescents
(state
worked with in this post
hrs/days
per week)
Present Post
Previous Employment
Additional Comments
TO BE COMPLETED BY
STUDENT:
I confirm that I will be able to
provide proof of my
qualifications
I confirm that I will be able to
provide an Enhanced DBS
(formerly CRB) dated on or
after 1/10/13
Submitted by:
(Head of Training)
Date:
PLEASE TICK
Please note: Heads of Training will be asked, at a later stage, to confirm that degree/diploma
certificates and Enhanced DBS (CRB) Disclosures have been checked by the Training School.
Please note: Heads of Training will be asked, at a later stage, to confirm that degree/diploma certificates and
CRB Disclosures have been checked by the Training School.
References
Applicants are responsible for ensuring all written references are provided before they can begin
their course. Please give the names and addresses of two people below, one of your choice and one
from your current work place in a senior position (line manager or supervisor).
Please do not use M7 seminar leaders as we contact them for additional references.
Please contact these referees yourself and ask them to send the references to us cpadmin@taviport.nhs.uk
All applicants must give details below of at least two different referees.
1. Name:*
2. Name:*
Job title: *
Job title:*
Email*
Email*
Relationship
Relationship