Accredited Membership Renewal Name(Required) First Last Street address(Required) Street address 2 (optional) Town/city(Required) County(Required) Post Code(Required) Country(Required) Mobile Number(Required) Home/Work Number Email(Required) 1. I am covered by professional indemnity insurance.(Required)Please give details, and indicate if this is provided by your employer.2. I currently practise therapy in a manner consistent with my accreditation as a psychoanalytic/ psychodynamic psychotherapist. I am practising ten hours per month with clients and/or supervisees.(Required) Please tick the box to confirm. 3. My arrangements for my own supervision are as follows:(Required)Please state the name and psychotherapeutic orientation of your supervisor or supervisors and state how frequently supervision takes place. Please note:- only psychoanalytic & psychodynamic supervisors are appropriate for the work you undertake for which you require UKCP registration.4. The UKCP requires psychotherapists on the Register complete Continuing Professional Development (CPD) activities, which can be any educational or professional activity that contributes to maintaining and developing psychotherapists’/analysts’ capacities, knowledge, skills and attitudes in order to enhance and improve the quality, safety and effectiveness of their clinical practice.The minimum quantity of hours of CPD set by UKCP is: Every 5 years: 250 hours, with no less than 20 hours in every year. Please record your CPD for the period: 1st June 2021 – 31st May 2022 below. Please tick appropriate boxes and specify details. i. More personal psychoanalytic or psychodynamic therapy. ListClick the + at the end of the row to add further rows.Date (i)Description (i)Number of hours (i) Add RemoveCPD continued ii. Seminars/Lectures about psychotherapy practice or theory. ListClick the + at the end of the row to add further rows.Date (ii)Description (ii)Number of hours (ii) Add RemoveCPD continued 2 iii. Short (e.g. weekend) professional courses related to psychotherapy practice or theory. ListClick the + at the end of the row to add further rows.Date (iii)Description (iii)Number of hours (iii) Add RemoveCPD continued 3 iv. Longer further professional training courses. ListClick the + at the end of the row to add further rows.Date (iv)Description (iv)Number of hours (iv) Add RemoveCPD continued 4 v. Other. ListClick the + at the end of the row to add further rows.Date (v)Description (v)Number of hours (v) Add RemoveUpload Record of CPDAlternatively, if you have recorded your CPD on the site, you can download your Record of CPD from your account and upload it here.Max. file size: 5 MB.5. Code of Ethics and Practice of the UKCP(Required) I have read the Code of Ethics and Practice of the UKCP and agree to abide by it. CRIMINAL CONVICTIONS/DISCIPLINARY PROCEEDINGS6. Membership of the Hallam Institute of Psychotherapy is exempt from the Rehabilitation of Offenders Act (1974), as it licenses you to practise in the public domain. You must therefore provide details of any criminal convictions which have not been notified to the HIP.(Required)Have you any criminal convictions which you have not already notified the HIP about? Yes No If yes, please send full details to Hallam Institute of Psychotherapy, c/o 16 Canterbury Crescent, Sheffield S10 3RX. This information will be kept in confidence and will be discussed with applicants only if the conviction is considered relevant to Re-accreditation of membership.7. Have you been subject to disciplinary procedures in a professional organisation of which you have been a member? If yes then please give details separately.(Required) Yes No 8. I acknowledge that membership of the Hallam Institute of Psychotherapy is exempt from the Rehabilitation of Offenders Act 1974 and that I must declare all previous convictions whether "spent" or otherwise. I hereby authorise the release of such information to the Hallam Institute of Psychotherapy and understand that this may involve verification of the information provided from police records.(Required) Please tick the box to confirm. PAYMENTPayment opt-outPlease pay online by completing the details below. (If you have already paid by another method or cannot pay online please check the box below to bypass online payment.) I have already paid by another method or I will contact Hallam Institute to arrange payment. Accredited Membership Annual Fee Price: Credit CardCard Details Cardholder Name DECLARATIONSigned(Required) Reset signature Signature locked. Reset to sign again Name(Required) Date(Required) DD slash MM slash YYYY
