Affiliates Application Form

Please complete the form below to apply to join our therapist network.

Title *
Surname *
First Name *
Address *
Address 2
Town *
County *
Postcode *
Daytime Telephone *
Evening Telephone
Mobile Telephone *
Email *
Date of Birth *
Current Position/Role
Education/Training:
Education 1 Date
Education 1 Institution
Education 1 Qualification
Education 2 Date
Education 2 Institution
Education 2 Qualification
Any Other Relevant Training
Attach /email CV *
Membership Numbers of Professional Bodies
HCPC registration number *
BPS Membership Number *
Insurance Company Treatment Provider Numbers *
Therapeutic Orientation
Work experience
Other Relevant Experience
Clinic Venues
Do you have your own consulting rooms? *
If so where?
Are you interested in using Happiness in Mind clinic venues in Manchester and Cheshire areas? *
What Geographical Locations do you cover? *
Are you able to provide home visits? *
Client groups (What Age Groups do you see?)
Child
Adolescent
Adult
Elderly
Availability
How much time do you have available?
Days
Evening
Weekend
What are your usual fees for assessment and treatment sessions for Clinical Psychology /CBT/EMDR/Counselling? *
References
Clinical Reference 1 Name *
Clinical Reference 1 Position *
Clinical Reference 1 Address *
Clinical Reference 1 Telephone Number *
Clinical Reference 2 Name
Clinical Reference 2 Position
Clinical Reference 2 Address
Clinical Reference 2 Telephone Number