Palmeira Practice - Membership Enquiry Form

Palmeira Practice - Membership Enquiry Form

This is a pre-meeting form for any counsellor / psychotherapist / psychologist or similar professional who is interested in joining the Palmeira Practice.
Thank you for your interest in the Palmeira Practice.
In order to progress your application to work with us, we'd appreciate if you could take a few minutes to tell us about yourself and your practice.
This form takes about 10 - 15 minutes to complete.

You can use the save button to save and come back to this page and pick up where you left off.
Name*

First NameLast Name
Email*

Confirmation Emailplease confirm email in lower box
Phone Number*
Please enter a valid phone number.
The Palmeira Practice ONLY accepts applications from practitioners who wish to join our Associate Scheme (where you work from your own room OR online OR a mixture of both), and you wish to receive client referrals from us. Is this what you're looking for? If yes, tick the box below. If no, please send us an email.*

YesNo

For what days/times are you hoping to receive referrals from the Palmeira Practice (please tick all the days/times you are planning to be available for referrals)?

	Mornings (8am onwards)	Afternoons (12pm onwards)	Evenings (4pm onwards)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

1. What client groups are you qualified to, or experienced in, working with?*

Adolescents (12 - 19 years)Young People (18 - 25 years)Ethnically Minoritised CommunitiesAdults (18+)CouplesChildren (5 - 11 years)LGBTQIA+ Communities
2. What top 3 specialisms would you want to offer if you were a member of the Practice? Eg, trauma, bereavement, EMDR, CBT, couples therapy, children, young people, etc.*
3. What counselling qualifications do you currently hold?*
Eg. Postgraduate Diploma from Brighton University
4. When did you first qualify as a counsellor or psychotherapist?*

MonthDayYear
Date
5. How many years experience do you have as a practising counsellor/ psychotherapist since qualifying? In order to join the Associate Scheme you will need to have 2-3 years post-qualification experience of working with clients.*
It may be that you have had breaks since qualifying, so please only count the years that you have been in practice.
6. Which membership body are you a member of?*
E.g., BACP, BPS, UKCP, etc
7. Are you accredited with your membership body*
8. What kind of therapy service do you want to offer to clients referred by The Palmeira Practice. Please tick all that apply.*

In-person at consulting rooms that I am renting.In-person at my home.Exclusively online.A mixture of in-person and online.
9. The Palmeira Practice generally receives more enquiries for in-person sessions, than online work. We are only able to consider applications from therapists working exclusively online if you are working in a specialism that the Practice needs to fulfil client demand. Please confirm you understand and agree to this. If you want to add narrative information about your specialisms, please use the final box at the end of the form*

Yes, I understand and agree.I work exclusively online, and will say more about my specialisms in the final answer box at the end of this form.
10. If you are offering to see clients in-person, where is your therapy room based? If you are part of some established Practice rooms, please give the name. Also provide the location of your therapy space (name of road and town), or say if you work from home. Explain all the places you work from in the space below.*
11. If you are offering in-person work you will be asked to provide at least one good quality photo of the therapy room(s) you work from (or usually work from) for your profile page on the Palmeira Practice website. Please confirm you are willing to do this.*

Please tick to confirm you will provide good quality photos of your consulting room.
12. The Palmeira Practice membership is limited in number. We believe this offers most therapists the best chance of getting a good number of referrals. We do not charge a monthly fee; we charge when you get a referral and the referral fee is the only income we receive. For this reason therapists who take less than 4 referrals from us per year may be asked to leave the Scheme, so their place can be given to someone else.*

Please tick to confirm your understanding of this.
13. What experience do you have of writing blogs about therapy issues? You can select up to three answers*

A little bit of experience - I'd be interested in seeing if I could do moreNone - I'm not interested in writing articlesWild horses couldn't persuade me to write a blogI'm a blog writing expert!None - I'm interested but haven't had the opportunity yetQuite a bit - I'd be interested in doing more
14. If you've written a blog / online article please cut and paste a link here
15. If you have a website please paste a link here:
16. And lastly, why do you want to join the Palmeira Practice Associate Scheme? You can also use this answer block to tell us about anything else.*
You can also use this field to tell us anything else that you haven't been able to tell us in the rest of the form.
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Palmeira Practice - Membership Enquiry Form

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