ࡱ> []Z bjbjVV .\<<%---AAA8y$At"QSSSSSS"!#S-"S3hX8-QQA?A`p=~0,T$T$T$- SST$ : BELFAST COGNITIVE THERAPY CENTRE Application to the BACP accredited POSTGRADUATE DIPLOMA IN COGNITIVE THERAPY Please return to: PG/Dip Applications 2011 BCTC Strand House 102 Holywood Road BELFAST BT4 1NU Name ______________________________________________________ Title (Mr/Ms) _________________________ Address _________________________________________________________________________________________________________ ____________________________________________________________ Postcode ____________________________ Phone Number _____________________________ E - mail _____________________________________________________ Marital Status ___________________________________________ DOB / Age____________________________________ Children (inc. ages) _____________________________________________________________________________________________ _____________________________________________ Date of Application __________________________  Please Note: Primary degree or professional qualification (e.g. nurse, social worker, counsellor) required. It is the responsibility of candidates to demonstrate that qualifications submitted are equivalent to primary degree or professional qualification. Highest Academic or Professional Qualification  Obtained From Date  Work Experience - Please begin with most recent (continue on separate sheet if necessary) Employer  From To Nature of Duties  Voluntary Experience Name of Voluntary Organisation  From To Nature of Duties Contact Person and Contact Details  Motivation to Train Professionally Please give your reasons for wanting to embark on professional therapist training at this time in your life.   Referees: Please give name and contact details of one recent academic and your most recent employment referee Academic:  Employment: Please outline experience and qualifications as a therapist  Please outline any experience as a client  Time Commitment Trainees attend 1 day per week in Yr 1 and 2 days per week in Yr 2. How will you manage this time commitment? Please also indicate whether your employer agrees to releasing you to fulfil this time commitment   Special Needs Do you have any disabilities or special educational needs? Yes/No (Please circle) If yes, please give brief details.   Finance If you are self-financing have you considered how you will undertake payment of Course fees? (Please see fees note enclosed)   Personal and Professional Demands Do you foresee any difficulties in coping with the rigorous academic and personal demands of professional therapist training? If so how might they be overcome?   Criminal Offences By virtue of the Rehabilitation of Offenders (Exceptions) Order (NI) 1979 and because the Clinical Placement in Year 2 requires that you will be working with vulnerable adults, this application is exempt from the provisions of Article 5 of the Rehabilitation of Offenders (NI) Order 1978. Accordingly you are not entitled to withhold information about convictions, which would otherwise be considered as spent under the provisions of the 1978 Order. Failure to disclose such information could result in dismissal from the course.  Please state whether or not you have been convicted of any criminal offences YES / NO. If YES, please give details below. It should be noted that convictions for offences do not necessarily debar an applicant from obtaining a place on the course.  Where did you hear about this Course?   I confirm that the information I have given in this application is, to the best of my knowledge, complete and accurate.  Signature: ______________________________________________________ Date: ________________________      PAGE  PAGE 4 #$%GHIst ! " ? 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