Application for Full Accreditation

ASSOCIATE MEMBERSHIP APPLICATION FORM Associate Membership of BABCP is open to anyone with an interest in the practice and theory of behavioural and/or cognitive psychotherapy but is not working in any healthcare or psychotherapy profession in a paid capacity. Membership runs for 12 months from when your application is processed. You can complete this form on your computer, please print out and sign where required, and return by post to: BABCP, Imperial House, Hornby Street, BURY, BL9 5BN or by fax to 0161 705 4306 or you can scan and send by email to [email protected] Required fields are indicated with an asterisk *

Surname*

First name(s)*

Mr Mrs Ms Miss Dr Professor Title* Other (please state)

Date of Birth*

Home Address* Post Code

Do you wish to use this address for correspondence? Yes No . If you check no please enter the address you wish to have BABCP correspondence sent to and other contact details. Please enter at least one telephone number.

Correspondence Address Post Code

Tel. Day Tel. Eve Tel. Mobile

Email (Required)*

Members Directory

Your name and county will be registered in the member directory.

Behavioural and Cognitive Psychotherapy Journal

Associate Members will receive online access to the Association’s journal Behavioural and Cognitive Psychotherapy (BCP) and the e-journal the Cognitive Behavioural Therapist (tCBT)

1 v0917 Criminal, Civil, Investigatory & Disciplinary Declarations

All applicants must answer each of the questions below. If you need to add any information please write this on a separate sheet and submit it with this application.

Additional Question Declaration Statement Enclosed Have you ever been convicted of any criminal offence in any court in Yes the UK or elsewhere which might prejudice the public’s trust in you, your profession, or the BABCP, if accurately informed about all the No circumstances of the case? Yes Have you ever been found guilty of a civil offence? No

Have you ever been refused/expelled from membership of any other Yes professional body/register on the grounds of professional misconduct or other professionally related offence? No Yes Have you ever been the subject of any professionally related disciplinary action (which may or may not have ended in dismissal)? No Yes Are you currently/likely to be the subject of any criminal, civil, investigatory or disciplinary proceedings or enquiries? No

To your knowledge, have you ever been, or are you likely to be Yes involved in a situation or incident likely to result in disciplinary action against you as a member of the BABCP? No

DELIBERATELY FALSE STATEMENTS WILL RESULT IN CANCELLATION OF YOUR MEMBERSHIP

Declaration

I wish to apply for Associate Membership of BABCP and accept as such that membership does not confer any professional status or qualification and I will not advertise myself as a member of BABCP.

I declare that I am not providing any form of psychotherapy or healthcare in a professional (paid) capacity

I agree to the aims of the Association and I will adhere to the Standards of Conduct, Performance and Ethics and such other rules, regulations and by-laws imposed on me by the Association from time to time.

By signing this declaration, I warrant that the information contained in this application and any accompanying papers is true accurate to the best of my knowledge and authorise BABCP to validate any of the claims set out in this application.

Signature Date

2 Subscription rates valid from 1 October 2017 until 30 September 2018

MARK ONLY ONE SUBSCRIPTION BOX. PLEASE ENSURE THAT YOU HAVE CHOSEN THE CORRECT SUBSCRIPTION FOR YOUR PAYMENT TYPE

Subscriptions paid by Cheque/Debit Card/Credit Card UK & Ireland Associate Member Subscription £28.40 Outside UK & Ireland Associate Member Subscription £36.50

Subscriptions paid by Direct Debit (UK bank accounts only) UK & Ireland Associate Member Subscription £20.25 Outside UK & Ireland Associate Member Subscription £28.40

In order for BABCP to offer a discounted rate for Direct Debit payments no reminders are sent out when the renewal is due. Your subscription will automatically renew 12 months from the date it is processed; this will be detailed in your welcome letter. If you choose not to renew you should contact BABCP at least five working days before your renewal date and cancel your Direct Debit instruction at your bank. If you forget to do this you should contact us within 14 days of payment being taken to receive a refund.

Signature Date

Signing your name here denotes acceptance of the terms of subscription

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