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.
Are you enquiring to join as a standard member (hire rooms from us) or as an associate member (work from your own room)?*

StandardAssociate

When are you hoping to work with us (please tick all the days/times you are interested in)?

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

1. Thinking about your answers to the last question, are you hoping to work at the Palmeira Practice*

for SOME of the above checked days /timesfor ALL of the above checked days /timesOR, I've ticked all the times I can do to see which times you have available for hire
2. 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
3. What top 3 specialisms would you want to offer if you were a member of the Practice? Eg, trauma, bereavement, EMDR, CBT, couples therapy etc.*
4. What counselling qualifications do you currently hold?*
Eg. Postgraduate Diploma from Brighton University
5. When did you first qualify as a counsellor or psychotherapist?*

MonthDayYear
Date
6. How many years experience do you have as a practising counsellor/psychotherapist since qualifying?*
It may be that you have had breaks since qualifying, so please only count the years that you have been in practice.
7. Which membership body are you a member of?*
E.g., BACP, BPS, UKCP, etc
8. Are you accredited with your membership body*
9. While we are able to offer referrals through the Palmeira Practice website, we require all of our therapists to have their own marketing up and running prior to joining. What marketing do you have in place?*

Counselling Directory ListingPsychology Today Directory ListingIt's Good To Talk (BACP) ListingOther marketingGoogle AdwordsOther Directory ListingOwn Website
10. Please use this space, if you need it, to qualify your answers to the last question. For instance, if you ticked 'other' or want to explain your marketing plans.
11. In your view, how effective is your current marketing? Tell us about it.*
12. How many clients do you currently see in private practice? *
13. What was the main route of referral for these clients? i.e. your own website, counselling-directory, word of mouth etc *
14. What is your current situation? You can select up to two answers*

I am not currently working as a therapist, and want to start up in private practice.I am working as a therapist for an agency/organisation, and want to start up in private practice.I am working in private practice already and looking to expand my practice into a different venue/location.I am working in private practice already and looking to move my clients/practice to a new venue and am considering the Palmeira Practice for this.I am returning to private practice after a break (e.g caring responsibilities, illness, other reason.
15. If you join the Palmeira Practice where would you be seeing your clients? Please tick all that apply.*

At the Palmeira Practice rooms.At a consulting room that I rent privately/independently (in person or online).At my home (in person or online).Exclusively online.At consulting rooms that are rented from an agency, organisation, or clinic, in person or online.
16. Where is your consultancy room based?*

I intend to use the Palmeira Practice roomsBrighton&HoveEast SussexWest SussexOther
17. What experience to 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
18. If you've written a blog / online article please cut and paste a link here
19. Here's another opportunity to provide us with a link to a blog / online article that you've written:
20. If you have a website please paste a link here:
21. And lastly, why do you want to join the Palmeira Practice?*
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

Thank you for completing this form