Service Provider Application

Title:
Name:

Address:

Phone:
E-mail:
Fax:

Qualifacations:

Personal profile including relevant experience and preferred therapeutic style:

Details of current employment:

Details of professional supervision received:

Details of registration with BACP or other recognised professional body:

Details of licence and insurance to work in a therapeutic setting:

Names and contact details of two proffessional people who are able and willing to verify your suitability to work with young people:

To which code of ethics do you adhere?:

Availability: days and times and venues:

Cost of counselling sessions per hour:

Any other details you think might be useful to us:

I confirm that I wish to be added to te list of service providers used by P.E.A.C.H.Y.

Signed:
Date: