Training Registration Form

Theraplay Training Registration Form
Completion of this form is required prior to the start of the training course and you, the training host, Theraplay UK, and The Theraplay Institute may each receive a copy of your submission as required. If you have any questions, please contact the training provider or admin@theraplay.org.uk.
General Information
Name*

First NameLast Name
Email*
example@example.com
City, County, Country*
Which training are you registering for?*
Who is the training host? If you are joining the Practicum, please provide the name of your supervisor (if known).*
Current Training, Practicum, and Certification Status (please select all that apply)*
Theraplay Training Eligibility
Clinical Responsibility: After completing Level 1 or Level 2 Theraplay® training, you should describe your work as ‘based on Theraplay® principles’ and you should describe your assessments as ‘based on the Marschak Interaction Method (MIM)’. You cannot say that you are ‘doing Theraplay’, or describe yourself as a ‘Level 1/Level 2 Theraplay practitioner/therapist’.

If you enroll on the Theraplay® practicum and complete Foundational Stage, you can describe your work as ‘Theraplay® Informed Practice’.

Only when you complete all three stages of the practicum, can you refer to yourself
as a ‘Certified Theraplay® Practitioner’, describe your work as ‘Theraplay®’ and say
that you are ‘carrying out a MIM assessment’.
I will use Theraplay-informed practice in my work as I am an accredited/registered member of a professional body that requires me to work within a framework of ethical practice and has a complaints procedure in place, which clients can access.I will only use Theraplay-informed practice in an employed role where the organisation that employs me holds clinical responsibility for my work and has a complaints procedure in place to respond to clients.
Professional Liability Insurance: I confirm that my work will be covered by appropriate professional liability insurance for Theraplay-informed practice, held either personally or via my employment.
Professional Liability Insurance: Please select the option that best applies to you*

Confidentiality Agreement for Participation in Theraplay Training

By signing this document, I agree to the following statements:

For Face-to-Face, Virtual, or Hybrid Training:
- I will not audio/video record any of the training content.
- In no way will I copy or electronically register the content of the Theraplay training handouts.
- I will not discuss the details of client information that I observe during the training.
- I will refrain from allowing anyone but myself to view virtual components of the training
Failure to follow these guidelines will result in no credit earned for the course and is subject to legal recourse.
Yes

The Theraplay Institute and Theraplay UK Data Sharing Consent Form
(Updated February 3, 2023)

This consent form applies only to information shared between The Theraplay Institute (TTI) and Theraplay UK.

We need your explicit consent for the following in order to maintain accurate training and administrative records, to support you through the supervision and certification process, and to maintain your certification once you have completed your training.

View TTI's privacy policy
View Theraplay UK's privacy policy

If you opt out of sharing information related to training, certification, or membership status, this may impact your ability to participate in the supervision and certification programs. At the discretion of the organisation holding the related information, you may still be approved to participate in Level One, Level Two, independent supervisions outside of practicum, or membership.

Opting out of promotional/marketing email announcements will have no impact upon your participation or eligibility to participate in the training programs.

You may opt out of any of your approvals, update your contact information, request information about your stored data or request deletion of your data at any time by contacting Theraplay UK at admin@theraplay.org.uk and The Theraplay Institute at amber@theraplay.org.
Theraplay UK may share my name, contact information, required documentation and training levels (once completed) with TTI so that both organisations may maintain verification of the training I have completed, or will be hosting, and support me with general account administration. This will be in the form of training registers, containing personal contact details, which will be sent to TTI upon the conclusion of each training. Please note: if you opt out of this approval, you will not receive a certificate following successful completion of a training course. Should I complete a Theraplay training held outside of the UK, TTI may send my name, contact information and training details to Theraplay UK for the same purpose. *
Theraplay UK and TTI may share my name, contact information and required documentation when I have registered for the practicum, as well as my ongoing certification progress, status and performance. This information may also be shared with a regional supervisor as part of the practicum process or the supervisor matching process (if the practitioner is seeking supervision only and is not joining the practicum).*
If I am in the train-the-trainer or train-the-supervisor program, Theraplay UK may share my name, contact information, required documentation and training status with TTI, as well as my ongoing status once approved.*
TTI may share my name, required documentation, current membership status, current continuing education fulfillment status (as applicable) and contact information with Theraplay UK. As membership and continuing education are required components of the practicum and certification, this information is necessary for Theraplay UK and TTI to know that I am meeting all requirements and keeping my certification in good standing once received.*
I am interested in receiving email notifications about upcoming trainings, practicum, membership, regional announcements and news. Please note: you will still receive notifications regarding your purchases and registrations from the affiliated organisation regardless of your selection here.*
Participant Signature
Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Should be Empty:

Theraplay Training Registration Form