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Address
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Postcode
Daytime Telephone
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Evening Telephone
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Email
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Date of Birth
Current Position
Education/Training
Education:
Dates/Institution/Qualification
Any Other Relevant Training:
Dates/Institution/Qualification
Membership of Professional Bodies:
HCPC registration number:
BAPCP registration number:
DBS registration number:
Data Protection number:
BPS Membership Number:
Theraputic Orientation:
Work Experience :
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Other Relevant Experience:
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Do you have your own consulting rooms?
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If so where?
What is your usual fee for CBT/EMDR Therapy?
What Geographical Locations do you cover?
Are you able to provide home visits?
Yes
No
What Age Groups do you see?
Child:
Adolescent:
Adult:
Elderly:
How much work would you like to do?
eg 1 day per month
Clinical Reference:
Name Position Address Postcode Telephone (day)
Clinical Reference:
Name Position Address Postcode Telephone (day)
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