Mental Health Form » IPRS Health

1. Personal Details

Therapist name:

Business name:

Business tel. number:

Business email:

Clinic website:

Business / clinic opening hours:

Address of business / clinic details:

Is your premises wheelchair accessible?

2. History

Do you hold professional accreditation with a relevant professional body? If not, please do not continue with the application

Name of accrediting body:

Accreditation Number:

ICO registration Number:

Modality:

CBT
EMDR
IPT
Counselling
Counselling for depression
Clinical psychology
Psychiatry
Other (please give details below)

Other experience:

CYP Experience:

Have you ever received specific training to enable you to work in children and young people’s mental health services? Please include the name of the course.

Do you have experience working in a CYP IAPT / CAMHS service? If so, which disorders did you treat?

Can you provide therapy in languages other than English?

Has the professional body ever placed any suspension, caution or condition on your membership or accreditation?

3. Fees

Please provide your rates for an initial assessment and treatment sessions in the boxes below:

Face to Face Initial Assessment:

Face to Face Treatments:

Tel / Virtual Initial Assessment:

Tel / Virtual Treatments:

4. DBS

Do you have an enhanced DBS certificate, dated within the last 3 years (from the certificate issue date)?

Issue Date:

Certificate Number:

Do you have the update service?

If yes, please provide update service number:

6. Disclaimer

By submitting this application you certify that your answers are true and complete to the best of your knowledge, and that you agree to IPRS keeping your data on file for a minimum of 5 years. For more information please see our privacy statement below.

If this application leads to affiliation, you understand that false or misleading information in this application may result in your affiliation being revoked.