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					                                                 Register of Independent Counsellors


                                               Application Form

(Please note that this application form supersedes all previous versions)

Please ensure all sections of the form are completed as appropriate.

*Surname:                                                  *Forenames:

*County or major city:

*Accrediting Organisation:                      BACP              COSCA   FDAP        UKAHPP
[Circle as appropriate]

Professional Body membership / reference No:


*These are the minimum details required for publication. It is a condition of registration that
these details are published.

Date of accreditation:

Certificate Name:

[Please state your name as you would like it to appear on your certificate.
N.B. It is not UKRC policy to include titles on certificates]

PUBLICATION OF THE REGISTER

The minimum details required for publication are those above marked with an asterisk*.
Additional details may also be published. Please complete the following sections for the
additional details you wish to be published:

Address:



Postcode:                                      Telephone :
                                               Mobile:
Web address:                                   E-mail:

Will you take referrals directly from clients?                             Yes / No
[Please circle your response]




                                                                                         PTO


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THE UKRC (INTERNET) WEBSITE
Your details will not be placed on the website unless you give your consent.
Please note that information placed on the website will be accessible by anyone with access
to the Internet.

Please tick one of the following statements:
I do not want my details published on the UKRC website.

I want all my details published on the UKRC website.

I want my minimum details only published on the UKRC
website. [*See over]

YELLOW PAGES
UKRC has negotiated a corporate advertising scheme with Yellow Pages. Registered
Independent Counsellors can have, for linage rates, a display advertisement under the UKRC
logo. With your permission we can arrange for Yellow Pages to send you details of the
scheme.

Do you want your name, address and telephone number
forwarded to Yellow Pages:                                                                 YES / NO
[Please circle your response]

FEES
The Registration fee is £30 per annum (Please see Information for Applicants). The first
year’s fee should be included with your application. Cheques should be made payable to
BACP. If you have a direct debit with BACP, do you wish future registration fees to be
added to it?                                                             YES / NO

DECLARATIONS
I declare that:
 I am currently an accredited counsellor in good standing with my professional body.
 I have read and accept the conditions for registration as a UKRC Registered Independent
    Counsellor.
 I understand that my registration, if granted, is dependent upon my accreditation. Should my
    accreditation cease, my registration will be cancelled.
 All information contained in this application is accurate to the best of my belief and knowledge.
 Details given may be published.

    I have not been and am not currently affected by any formal complaints procedures within
     any professional body of which I am a member.
     [If you have been or are currently the subject of a complaint where the complaint is upheld and /or rights of
     membership are suspended, you are bound to declare this with your application.. All involvements in
     complaints or disciplinary procedures have to be investigated and may delay the processing of an
     application.

    I have not been refused or been removed from membership of any professional body. If you have
     been refused or removed, please give details on a separate sheet.



Signed:……………………………………..                                           Dated………………………………..

Please return your application, with evidence of insurance cover and the fee to: UKRC,
BACP House, 15, St John’s Business Park, Lutterworth, Leicestershire, LE17 4HB. Tel:
0870 443 5232

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