Application for Admission to Read for THE PRACTITIONER DOCTORATE (PsychD) IN PSYCHOTHERAPUTIC AND COUNSELLING PSYCHOLOGY SEPTEMBER 2013

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1 Application for Admission to Read for THE PRACTITIONER DOCTORATE (PsychD) IN PSYCHOTHERAPUTIC AND COUNSELLING PSYCHOLOGY SEPTEMBER 2013 Please ensure that you have first completed the University of Surrey online Research Degree Application Form, and return this form to FAHS Admissions, 10 AD 04, University of Surrey, Guildford, Surrey, GU2 7XH For office use only Personal Details Last name: Title: (Miss/Ms/Mrs/Dr/Mr) First Names: Address for correspondence: Date of Birth: Nationality: Female/ Male: Home address (if different): address: Telephone: Current Occupation Mobile: Telephone: Do you need a work permit to work in the UK? Do you have the Graduate Basis for Chartered Membership (GBC) of the British Psychological Society? (See note page 5) If not, will you be eligible to apply for GBC on successful completion of your degree? Or, are you awaiting the decision of the BPS regarding GBC? Please state any health needs (physical or emotional) or physical disabilities that may require special facilities or equipment during the selection day, during training or throughout the course of placements. 1

2 FULL OCCUPATIONAL HISTORY (INCLUDING VOLUNTARY WORK) SINCE LEAVING SCHOOL List in reverse order, starting with your current occupation. Job Title (State if voluntary) Employer/ Voluntary agency Dates From - To - Full/ Part time (hours per week) 2

3 Research Experience (Research training, projects undertaken and any publications) Experience of Therapeutic Settings (Your role, responsibilities, type of supervision etc.) Any therapeutic Training and Experience (Details of training, types of client, number of client hours, type of client work) Other Relevant Experience (Experience of professional contexts. Explain the relevance to Psychotherapeutic and Counselling Psychology andcomment on what you have gained from the experience) 3

4 Reasons for applying for the PsychD Psychotherapeutic and Counselling Psychology Course (Please write between words about yourself and your reason for training as a Counselling Psychologist at Surrey. All information will be treated as confidential to the University.) Please use a continuation sheet if necessary 4

5 ADDITIONAL INFORMATION - Add any other information about yourself which you think is relevant, including activities and special interests apart from psychology. Are there any other factors which might be pertinent in assessing your application? Under the terms of the Local Authorities Social Services Act 1970, you are likely to be regarded as having substantial access to children. Therefore in accordance with the Rehabilitation of Offenders Act 1974 (Exceptions) Amendment Order 1986, you will be obliged to disclose both current and spent convictions. Do you have a criminal record? If YES please enclose a list of such convictions, bind over orders or cautions. Applicants should be aware that Trainees will be subject to checks by the Criminal Records Bureau during the course of their training. Signature. Date Please indicate how you heard about the course: Advertisement.. Careers Office. Lecturer. Other: Are you applying for other courses, either at Surrey or elsewhere? NB Applicants must additionally provide: The completed online Research Degree Application Form Transcripts of RELEVANT courses attended and examination marks awarded and/or copies of degree certificate(s). Your English Language certificate showing an IELTS score of at least 7, with no lower than 6.0 in any component (or equivalent qualification) if your first language is not English. This should have been obtained within two years of the start date of your programme. An abstract of research related coursework/dissertation. Details of 2 referees (including professional addresses), one of which must be able to comment on your recent academic ability, and the other on your relevant work experience (see Research Degree Application Form). A copy of the letter from the British Psychological Society confirming GBC, if this has already been granted. PLEASE NOTE THAT ANY ORIGINAL DOCUMENTATION SUBMITTED WILL BE RETURNED ONLY IF YOU REQUEST THIS BEFORE SEPTEMBER