General 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) There are three categories of General Membership.(Required)Please select the category under which are you making your renewal application. A. Persons who do not practice psychotherapy but who support the Aims and Objectives of the Institute. This will include retired members and those no longer practicing. B. Practising psychotherapists already holding UKCP registration, or registration through another recognised body. C. Persons supporting the Aims and Objectives of the Institute, who may be qualified and practicing in a core profession or associated area to psychotherapy. Registering Body(Required)Please give registering body. 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. General Membership Annual Fee Price: Credit CardCard Details Cardholder Name DECLARATIONI confirm that: I understand (Constitution clause 5.4) that being a General Member of the Hallam Institute of Psychotherapy does not constitute a professional qualification, and I will not represent it as such. I agree to abide by the Governing Documents and Standing Orders of the Hallam Institute of Psychotherapy (available on request) excluding the Code of Ethics, which only applies to Accredited Members.. I agree to abide by the rules of the organisation governing upholding the good name of the Hallam Institute and contact with the media. I confirm that all the information in this application is complete and correct and I understand that any false information given may make my application invalid and will lead to termination of membership. Signature(Required)Name(Required) Date(Required) DD slash MM slash YYYY
