Re-Instatement of Accredita�on Applica�on Form - - PDF document

Page 1 of 5 Re-Instatement of Accredita�on Applica�on Form - Part AIrish Association for Counselling and Psychotherapy Requirements for Re-Instatement of Accredita�on depend on how long your membership has been cancelled:  Once you meet all the above requirements please complete Part B DECLARATION OF APPLICANTI apply for Re-Instatement of my Accredited Membership. I con�rm that I agree to be bound by the IACP Memorandum and Ar�cles of Associa�on and to abide by the IACP Code of Ethics and Prac�ce. I con�rm the informa�on I have supplied is correct and true. I understand that any inaccurate or false informa�on or omission of material informa�on shall render this applica�on invalid. I www.iacp.ie Date: 1.PERSONAL DETAILS Date of Birth (dd/mm/y Membership No: Forename: Address: Phone (day�me): Page 2 of 52.DATE YOUR ACCREDITED MEMBERSHIP WAS CANCELLED (dd/mm/yy): Select category or Re-instatement you are applying for: Cancelled for less than 2 years Cancelled for between 2 and 7 yearsReason your Accredited Membership was cancelled: Why you wish to be re-instated: Signature: Date: Documents will be destroyed a�er an appropriate period of �me as per the IACP Reten�on policy. Do not send any original documents unless speci�cally requested.Keep a copy of any applica�on forms/correspondence you send to IACP for your own records. Page 3 of 5 Re-Instatement of Accredita�on Applica�on Form - Part BIrish Association for Counselling and Psychotherapy 1.PERSONAL DETAILS Date of Birth (dd/mm/yy): Forename: Membership No:Employer / Occupa�on: Work Address:Work Phone No: Address: Supervision must take place at least monthly with a minimum of 1 hours of supervision to every 10 hours of client contact work. If youprac�ce in morethan 1 loca�on please provide thetails on a separate sheet. Explain on a separate pagy gaps in your client work.e.g. Organisa�on or private prac�ce (Name and Loca�on) From (dd/mm/yy): To (dd/mm/yy): Your Role Nature of Client Work (Individual / group counselling etc.): Total Client Hours: Supervisor (Name & Accredi�ng Body) Group Supervision Hours: Individual Supervision Hour Total Supervision Hours: For Group Supervision: How o�en are the sessions? How many Supervisees in the group? Length of group sessions? Ra�o of Supervision Hours to Client Contact Hours: I con�rm that this ra�o of supervision to client contact hours has been met.Signature of Applicant: Date: Page 4 of 55.PROFESSIONAL LIABILITY INSURANCEName of Insurance Company: Policy Number: Expiry Date (dd/mm/yy): SUPERVISION IN THE LAST 12 MONTHS (To be completed by Supervisor) changed supervisor or have more than oneas necessary and complete a page fsupervisor used in theName of Supervisor: Supervisor Accredi�ng Body & Membership Number: Date of ini�al Date and period of currentSupervisor Accredita�on (dd/mm/yy): Supervisor Accredita�on (dd/mm/yy): Address: Contact Phone Number: Email Address: Start of Supervision End of Supervisionontract (dd/mm/yy): contract (dd/mm/yy) or Current: Frequency & length of supervision sessions: I recommend the reinstatement of the applicants IACP Accredita�on: Yes If No please state reason: Addi�onal Comments: I have read the applicant’s applica�on form which, to the best of my knowledge, is correct.Signature of Supervisor: Date: CONTINUING PROFESSIONAL DEVELOPMENT (CPD)Please submit details of the required number of hours of CPD activities that relate to ounselling /psychotherapy and have impacted your professional practice over the past 12months. CPD activities may include further training (given and received), seminars, shops, publishing articles, published research, committee work, etc. [N.B. This list is not exhaustive]. CPD ACTIVITY: brief descrip�on of the ac�vity No. of hours I am sa�s�ed that the above ac�vi�es have contributed to the personal and professional development of the applicant. Signature of Supervisor: Date: On a separate sheet of paper describe in more detail of the above ac�vi�es, relevant to your area of prac�ce, which you have listed. Provide reasons for choosing the ac�vity with reference to your prac�ce and show how the ac�vity has in�uenced your prac�ce. Remember to include the date of your ac�vity. Page 5 of 56.DECLARATION OF APPLICANTor Re-Instatement of my Accredited Membership. I con�rm that I agree to be bound by the IACP Memorandum and Ar�cles of Associa�on and to abide by the IACP Code of Ethics and Prac�ce. I con�rm the informa�on I have supplied is correct and true. I understand that any inaccurate or false informa�on or omission of material informa�on shall render this applica�on invalid. I understand that all applica�ons are at the discre�on of the Accredita�on Department and Re-instatement of Accredited Membership is not guaranteed.Signature of Applicant: te: Documents will be destroyed a�er an appropriate period of �me as per the IACP Reten�on policy. Do not send any original documents unless speci�cally requested.Keep a copy of any applica�on forms/correspondence you send to IACP for your own records. www.iacp.ie Page 1 of 5 Re-Instatement of Accredita�on Applica�on Form - Part AIrish Association for Counselling and Psychotherapy Requirements for Re-Instatement of Accredita�on depend on how long your membership has been cancelled:  Once you meet all the above requirements please complete Part Bof this applica�on form and return it to the IACP o�ce. All applica�ons are at the discre�on of the Accredita�on Department and Re-instatement of Accredited Membership is not guaranteed. Please complete using CAPIAL LETTERS and return to the IAC, First Floo, Marina House, 11-13 Clarence Street, Dun Laoghaire, DECLARATION OF APPLICANTI apply for Re-Instatement of my Accredited Membership. I con�rm that I agree to be bound by the IACP Memorandum and Ar�cles of Associa�on and to abide by the IACP Code of Ethics and Prac�ce. I con�rm the informa�on I have supplied is correct and true. I understand that any inaccurate or false informa�on or omission of material informa�on shall render this applica�on invalid. I understand that all applica�ons are at the discre�on of the Accredita�on Department and Re-instatement of Accredited Membership is not guaranteed.Signature of Applicant: Date: 1.PERSONAL DETAILS Date of Birth (dd/mm/yy): Membership No: Forename: Address: Phone (day�me): www.iacp.ie Page 1 of 5 Re-Instatement of Accredita�on Applica�on Form - Part AIrish Association for Counselling and Psychotherapy Requirements for Re-Instatement of Accredita�on depend on how long your membership has been cancelled:  Once you meet all the above requirements please complete Part Bof this applica�on form and return it to the IACP o�ce. All applica�ons are at the discre�on of the Accredita�on Department and Re-instatement of Accredited Membership is not guaranteed. Please complete using CAPIAL LETTERS and return to the IAC, First Floo, Marina House, 11-13 Clarence Street, Dun Laoghaire, DECLARATION OF APPLICANTI apply for Re-Instatement of my Accredited Membership. I con�rm that I agree to be bound by the IACP Memorandum and Ar�cles of Associa�on and to abide by the IACP Code of Ethics and Prac�ce. I con�rm the informa�on I have supplied is correct and true. I understand that any inaccurate or false informa�on or omission of material informa�on shall render this applica�on invalid. I understand that all applica�ons are at the discre�on of the Accredita�on Department and Re-instatement of Accredited Membership is not guaranteed.Signature of Applicant: Date: 1.PERSONAL DETAILS Date of Birth (dd/mm/yy): Membership No: Forename: Address: Phone (day�me):