Registration forms for NIP membership (complete, tick or circle as applicable)

Transcription

1 Registration forms for NIP membership (complete, tick or circle as applicable) 1. Personal information Surname... M/F Initials... Name.... Title(s)... Date of birth... Place of birth.... Address... Postcode and place... Telephone... Fax IBAN (Bank account number) Previous education Psychology go to 3a enclose: - photocopy of psychology degree certificate Psychology, and also BIG registered healthcare psychologist go to 3b (gezondheidszorgpsycholoog) enclose: - photocopy of psychology degree certificate - proof of registration as healthcare psychologist in the BIG register In training as a health care psychologist, school psychologist or go to 3c in the process of registering in a NIP register, which will lead to the title of Registerpsycholoog NIP. enclose: - photocopy of Master s or doctoral diploma in psychology, Pedagogical sciences, Master s in Mental Health - proof of registration in the study programme as health care psychologist, school psychologist Educational sciences, and also BIG registered healthcare psychologist go to 3c (gezondheidszorgpsycholoog) enclose: - photocopy of educational sciences degree certificate - proof of registration as healthcare psychologist in the BIG register NIP PO Box GB Utrecht phone (030) info@psynip.nl

2 Health sciences with the course orientation mental health (GGK), go to 3c and also BIG registered healthcare psychologist (gezondheidszorgpsycholoog) enclose: - photocopy of health sciences degree certificate with mental health (GGK) as course orientation - proof of registration as healthcare psychologist in the BIG register Student of Psychology go to 3d enclose : - photocopy of student ID card - proof of registration as psychology student (for Open University students, a copy of their course registration is sufficient) 3. Membership NIP has a number of different forms of membership with associated contribution categories. A list is included in the contributions leaflet. 3a Enrolment for: (previous education: Psychology) Membership A number of membership categories may be distinguished within ordinary membership. State below the category in which you are to be placed: working members new members who have only recently graduated (only two years ago) non-working members/members with unpaid work foreign members (working abroad) members with the Belgian licentiate in psychology graduate members in training as: healthcare psychologist (GIO) Enclose statement by principal trainer clinical psychologist through Postgraduate Vocational Training (KIO) Enclose statement by principal trainer BIG psychotherapist (PIO) Enclose statement by principal trainer (clinical) neuropsychologist (KNO) Enclose statement by principal trainer researcher (AIO and OIO) Enclose statement from university Candidate membership Only for psychologists with a foreign diploma not yet recognised in the Netherlands 1 ; not for psychologists with the Belgian licentiate in psychology (since they can become ordinary members) Were you previously an NIP student member? Yes No Have you been an NIP member before? Yes No continue with 4 3b Enrolment for: (previous education: Psychology, and also BIG registered healthcare psychologist) Membership A number of membership categories may be distinguished within ordinary membership. State below the category in which you are to be placed: 1 You do not need to complete questions 8 and 9 if you are enrolling as a Candidate Member. 2

3 working members non-working members/members with unpaid work foreign members (working abroad) graduate members in training as: clinical psychologist through Postgraduate Vocational Training (KIO) Enclose statement by principal trainer BIG psychotherapist (PIO) Enclose statement by principal trainer (clinical) neuropsychologist (KNO) Enclose statement by principal trainer researcher (AIO and OIO) Enclose statement from university Candidate membership Only for psychologists with a foreign diploma not yet recognised in the Netherlands Were you previously an NIP student member? Yes No Have you been an NIP member before? Yes No On the basis of your registration as a healthcare psychologist you can be granted the protected title of NIP PSYCHOLOGIST. You will automatically obtain the title by declaring that you have taken note of the Regulations for Use of the Professional Designation of NIP PSYCHOLOGIST (see enclosure). Accordingly, you do not need to complete the NIP PSYCHOLOGIST Application Form. I hereby declare that I have taken note of the Regulations for Use of the Professional Designation of NIP PSYCHOLOGIST: Date... Signature... now continue with 4 3c Enrolment for: (previous education: Educational Sciences or Health Sciences with mental health (GGK) as course orientation, and also BIG registered healthcare psychologist) Membership A number of membership categories may be distinguished within ordinary membership. State below the category in which you are to be placed: working members non-working members/members with unpaid work foreign members (working abroad) graduate members in training as: BIG psychotherapist (PIO) Enclose statement by principal trainer researcher (AIO and OIO) Enclose statement from university Membership for interest On the basis of your registration as a healthcare psychologist you can be granted the protected title of NIP PSYCHOLOGIST. You will automatically obtain the title by declaring that you have taken note of the Regulations for Use of the Professional Designation of NIP PSYCHOLOGIST (see enclosure). Accordingly, you do not need to complete the NIP PSYCHOLOGIST Application Form. I hereby declare that I have taken note of the Regulations for Use of the Professional Designation of NIP PSYCHOLOGIST: 3

4 Date... Signature... now continue with 4 3d Enrolment for: (student of psychology) Student membership On their enrolment as student members, students automatically become members of the Joint Sector, and of the Section for Psychology Students (SPS) within it. As well as this first preference, it is also possible to become a member of other sectors, sections and working parties. These can then be indicated as the second, third or fourth choice (see question 11 part II). now continue with 4b 4. Study details old style (to 1988) go to 4a two-phase structure (commencing 1982) go to 4b 4a old style (to 1988) Date of first degree examination (kandidaatsexamen)... Date of higher degree examination (doctoraalexamen)... University... Course orientation... 4b two-phase structure (commencing 1982) Date of preliminary examination... Date of higher degree examination (doctoraalexamen)... students: indicate expected graduation date University... Course orientation Doctorate if applicable Date... University... Subject... Professor since... Chair... 4

5 6. Membership of other professional associations o Nederlandse vereniging van pedagogen en onderwijskundigen (NVO) o Stichting voor Wetenschappelijk Onderzoek in de Psychologie en Psychonomie in Nederland o Nederlandse Vereniging voor Psychotherapie o Nederlandse Vereniging voor Neuropsychologie o Vereniging voor Gedragstherapie o Others, namely:... o Vereniging voor Cliëntgerichte Therapie... o Nederlandse Vereniging voor Groepspsychotherapie Trade unions o Nederlandse Vereniging voor Hypnotherapie o ABVA/KABO o Vereniging voor Kinder- en Jeugd- psychotherapie o AOB o Nederlandse Vereniging voor Relatie- en o Other FNV unions, namely:.... Gezinstherapie o CNV o Nederlandse Vereniging voor Personeelsbeleid o VHP o Orde van Adviseurs voor Werving en Selectie o Others, namely Work details Student members can skip 7 If you are registered as a working member (paid or unpaid) you can enter details of up to two employers on this page and the following page. If you (also) practise independently, indicate this by entering Independent practitioner and the name of your practice under Name of Organisation. Name of employer 1: Name of organisation... Address... Postcode and place... Telephone... Direct dial... Fax Employed since Number of hours per week... Paid Unpaid AIO/OIO/GIO/KIO/PIO Job description... Providing management NO / YES, to... persons Field of work Clinical psychology Social psychology Psychotherapy Education Care of mentally handicapped Careers guidance Forensic psychology Child and youth psychology Psychiatry Academic Research 5

6 Gerontology Other:... Employment and Organisation Psychology Pension provision NO / YES, through ABP other, through PGGM Collective agreement applicable NO / YES: (ask your employer) Hospitals CAO (CAO Ziekenhuizen) GGZ CAO (CAO GGZ) Handicapped Care CAO (CAO Gehandicaptenzorg) Nursing and Care Homes CAO (CAO Verpleeg- en Verzorgingshuizen) Teaching Hospitals CAO (CAO Academische Ziekenhuizen) Welfare Work CAO (CAO Welzijnswerk) Youth Assistance CAO (CAO Jeugdhulpverlening) Government, namely... Other collective agreement, namely. Name of employer 2: Name of organisation... Address... Postcode and place... Telephone... Direct dial... Fax Employed since Number of hours per week... Paid Unpaid AIO/OIO/GIO/KIO/PIO Job description... Providing management NO / YES, to... persons Field of work Clinical psychology Social psychology Psychotherapy Education Care of mentally handicapped Careers guidance Forensic psychology Child and youth psychology Psychiatry Academic Research Gerontology Other:... Employment and Organisation Psychology 6

7 Pension provision NO / YES, through ABP other, through - PGGM Collective agreement applicable NO / YES: (ask your employer) Hospitals CAO (CAO Ziekenhuizen) GGZ CAO (CAO GGZ) Handicapped Care CAO (CAO Gehandicaptenzorg) Nursing and Care Homes CAO (CAO Verpleeg- en Verzorgingshuizen) Teaching Hospitals CAO (CAO Academische Ziekenhuizen) Welfare Work CAO (CAO Welzijnswerk) Youth Assistance CAO (CAO Jeugdhulpverlening) Government, namely... Other collective agreement, namely. 8. Declaration in respect of professional code I declare that in the performance of my activities as a psychologist I shall be guided by the professional code for psychologists as described in the Professional Ethics for Psychologists who are NIP Members. I declare that if complaints are made to NIP about my practice or my attitude as a psychologist I shall submit to an investigation by the supervisory Boards. As a student, I shall be guided by the Professional Ethics for Psychologists who are NIP Members in my practical work with persons (work placements). Date... Signature Declaration in respect of the provision of personal information NIP receives regular requests to provide members name and address details so that invitations for congresses and study days can be sent to them or publications can be recommended to them. Where the purpose for which the addresses are provided is not contrary to the Dutch Data Protection Act (Wet Persoonsregistratie) the information provided by you to NIP will be made available to third parties. If you object to this being done, please indicate below. I agree / do not agree that my personal details may be made available to third parties so that information material may be sent to me. Date... Signature... 7

8 10. Membership commencement date / Payment method for contribution Indicate below when you wish your membership to commence: 1st quarter 2nd quarter of the 3rd quarter calendar year... 4th quarter New members are requested to pay the registration fee within two months after enrolment. The contribution is charged per quarter with effect from the quarter in which you become a member. That payment must also be made within two months after enrolment. You can choose one of the following payment methods. Indicate which you prefer. Payment in instalments by direct debit Payment may be made in instalments only by a direct debit mandate. The contribution payable will then be collected from your account in two instalments (1 January, 1 July). Single payment by direct debit (1 January). If you enrol after the above dates you will be sent a giro collection card for the current year and will be required to pay within two months. If you do not agree with the deduction, you have a period of one month within which you can ask your bank or postbank to have the money transferred back. To do so, send the yellow card to your bank or postbank. You can also cancel the mandate. To do so, send the enclosed red card to NIP. Allow some time for processing after you send it in. I have noted that if I wish to terminate my membership I must give notice in writing before 1 December of the year in question. The undersigned declares that he/she agrees to the payment arrangements as set out above. Date... Signature Registration form for sectors, sections and working parties NIP consists of four different sectors: Employment and Organisation Sector Healthcare Sector Youth Sector Joint Sector 8

9 A range of sections and working parties are active within these sectors. A list of the sections and working parties per sector has been included in the NIP information file for orientation. Below you can indicate which sector you wish to join. All members, including members for interest, must state at least one sector, but it is also possible to be a member of two or more sectors. On their enrolment as student members, students automatically become members of the Joint Sector, and of the Section for Psychology Students within it. (Note that you must list this as your first preference for the sector if you are a student.) As well as this first preference (see below), it is also possible to become a member of other sectors, sections and working parties. These can then be indicated as the second, third or fourth choice. I. Choose your sector You can indicate an order of preference based on your interest. Membership of two or more sections does not affect your contribution. First preference for the sector... * 2nd choice... 3rd choice... 4th choice... Students should enter Joint Sector here. II. Choose your section and/or working party There are sections and working parties active within each sector. Below you can indicate which section(s) and which working party or parties you wish to join. Students must at least list the Psychology Students section (see D). A. Sections and working parties within the Employment and Organisation Sector Employment and Health Psychology Section Training and Education Section People, Work and Organization Section B. Sections and working parties within the Healthcare Sector Psychologists in Mental Healthcare Section Psychologists in General/Academic Hospitals Section* open only to members working in hospitals First-Line Psychologists Section* Psychologists in Care for the Elderly Section Care for Persons with a Mental Handicap Section Rehabilitation Psychology Section Forensic Psychology Section Neuropsychology Section 9

10 * An additional contribution is charged by this section. See the information sheet for the Healthcare Sector (included in the enrolment folder) C. Sections and working parties within the Youth Sector Auditory Handicaps Section open only to members working in the section s field School Psychologists Section Justice Section The Young Child Section Youth Care Section D. Sections and working parties within the Joint Sector Within this sector there is scope for new initiatives covering a wider area than the previously mentioned sectors. The following sections and working parties are already operational within the Joint Sector: Section for Psychology Students (SPS) Interculturalisation Section Mediation Section Student Psychologists Working Party open only to members working in this area Body-Oriented Psychologists Section Researchers in Psychology Section (WOP) Neurofeedback Working Party N:\vl\infobladen\engelsformulierlidmaatschap.doc/