Application for registration as
an EMPATHY Counsellor

Empathy Counsellors must hold a degree or diploma in counselling and be accredited, or show they are working towards accreditation by BACP, UKCP or other recognised accrediting body.Counsellors must be in regular supervision and be committed to continuing professional development. If your application is successful you will be required to apply for a Standard CRB (Criminal Records Bureau) disclosure. (Information about the Disclosure can be found at www.crb.gov.uk or by contacting the information line on 0870 90 90 811).

Following an offer of registration and its acceptance, which will be subject to the receipt of satisfactory references, Empathy will require copies of the Counsellorís diploma/degree, current accreditation and insurance certificates. Copies of accreditation and insurance certificates are required to be submitted on their renewal.

Section one: Personal and professional information

Name

Address

Telephone

E-mail

Qualifications

Name and address of awarding University or College

Accrediting organisation and membership number

Details of professional Indemnity Insurance (insurer and ref. no.)

Section two: consulting room

Practice address

Referal telephone number

Please indicate which days and times you would be available

Section three: Supervision

Name and address of Supervisor

Number of supervision hours per month

Section four: Referees

Please give the names and addresses of two referees, one of whom should be your Supervisor as above. Family members should not be used.

Name and address of first referee

Name and address of second referee