Name
Date
Current Institution/Organization and Title (if any):
Please Insert a picture of yourself
Work Address
Town / Postal Code
Home Address
Town / Postal Code
Work Telephone
Home Telephone
Mobile Phone
Fax
Primary Email Address
Alternate Email Address
Website
*Be sure to include your country code, and city code
If funded by an organisation/employer, details needed for invoicing
List or describe your reasons for undertaking training in Schema Therapy
Education & Work Experience
Highest Degree
Year Earned
Field
Please explain the degree(s) you have obtained, and the exact field of study. (Please include how many years of study are invovled)
University (Include city and country)
Describe your Internship(s), Practicum Work, or Residency (including name and location of Institutions)
Describe Graduate Level Training (Post-Graduate Certificate, Masters, Post-Doctoral training)
Professional Accreditation(s) / Licensure / Certification (if required for practice in your field of work)
Membership Number
Professional Body / Country
List previous workshops and training in Schema Therapy, if any (include approximate dates, locations, hours, and instructors)
Direct patient contact
Supervise Other Therapists
Administration
Take Courses
Research
Teach / Conduct Training
Other Activities (please specify)
Current Work Setting / Organisation
Current Position / Title
I currently work with:
(Rate each category on a scale from 0-3 as follows: 0 = not at all, 1 = occasionally, 2 = frequently, 3 = almost always)
Inpatients
Children
Individuals
Outpatients
Adolescents
Couples
IAPT/Partial Hospital Patients
Adults
Families
Criminal Offenders
Geriatrics
Groups
Employment / Work Related Counselling
Domestic Violence Perpetrators
Domestic Violence Victims
Education
Other (please specify
Please elaborate on your current professional work, including training, research, administrative and/or clinical activities.
Please elaborate on the nature and amount of clinical training in Schema Therapy you have already received. Include the number of patients you have treated.
Please elaborate on your general clinical training and previous clinical experience. Inlcude the number of supervised hours undertaken during your training in the space below.
Number of supervised clinical hours undertaken during your training
How did you hear about us?
Search engine
Twitter
Facebook
Word of Mouth
ISST Conference
Other
As well as responding to this enquiry, we'd love to keep you informed of other training courses we run. We'll always treat your personal details with the utmost care and will never sell them to other companies for marketing purposes.
Send
