PsychD in Psychotherapeutic and Counselling Psychology Application

							                                    Application for Admission to Read for
                                THE PRACTITIONER DOCTORATE (PsychD)
                        IN PSYCHOTHERAPEUTIC AND COUNSELLING PSYCHOLOGY
                                             SEPTEMBER 2010

  When completed this form, together with the Research Degree Application form, should returned to The Postgraduate
               Admissions Office, The Registry, University of Surrey, Guildford, Surrey GU2 7XH.




                                                                                                            For office use only
Personal Details
Last Name:                                                      Date of Birth:

Title: (Miss/Ms/Mrs/Dr/Mr)                                      Nationality:

First Names:                                                    Female/Male:

Address for correspondence:                                     Home Address (if different):




E-mail address:
Telephone:                         Mobile:                      Telephone:


Current Occupation



Do you need a work permit to work in the UK?                                                            Yes/No

Do you have the Graduate Basis for Chartered Membership of the British Psychological Society?           Yes/No
(see note page 5)

Will you be eligible to apply for GBC on successful completion of your degree?                           Yes/No

Are you awaiting the decision of the BPS regarding GBC?                                                  Yes/No


Please state any health needs or physical disabilities that may require special facilities or equipment during training.


FULL OCCUPATIONAL HISTORY (INCLUDING VOLUNTARY WORK) SINCE LEAVING SCHOOL
   List in reverse order, starting with your current occupation.

Job Title                               Employer/Voluntary Agency   Dates           Full /Part-time
(state if voluntary)                                                From -   To -   (hours per week)




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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 and
comment on what you have gained from the experience).




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Reasons for applying for the PsychD Psychotherapeutic and Counselling Psychology Course
(Please write between 500-1000 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


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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?                                                                                                                                Yes/No
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: ………………………………………………………………………………………………………………….


NB Applicants must additionally provide:

      •     The completed Research Degree Application Form.

      •     Transcripts of RELEVANT courses attended and examination marks awarded and/or copies of degree certificate(s).

      •     An original copy of your English Language certificate showing either a Cambridge Proficiency Certificate at Grade
            C (or higher); a TOEFL score of at least 89-90 on the internet based test, or an IELTS score of at least 6.5, 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, 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.




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