Supervision Registration

Welcome to Supervision registration with Adam C Therapy. The below form is to be completed once a Clinical Supervision consultation has taken place. If you have not arranged this yet please make an enquiry to discuss before proceeding.

Clinical Supervision Intake Form

Please complete this form to access professional clinical supervision services in the UK.

First name

Last name

Email address

Phone number

Date of birth

Day

Month

Year

Address Information

Home address

Home Address

Country/Region

Address

City

Zip / Postal code

Clinical practice details

Practice name

Clinical Practice Address

Country/Region

Address

City

Zip / Postal code

Country/region

If your practice is located outside the UK, please specify the country/region

Emergency Contact

Emergency contact name

Emergency contact phone number

Relationship to you

Professional Information

Current job title/role

Employer/organisation

Professional bodies & registration number(s)

Please provide your registration numbers with the relevant professional body (e.g., BABCP, BACP, NCS, UKCP, BPS, HCPC)

What modalities are you trained in and developing in?

Years in practice

Are you currently a student counsellor?

Yes

Professional indemnity insurance

Please upload a copy of your current professional indemnity insurance certificate (optional)

I confirm that the above information is accurate and complete. I consent to this information being processed for the purposes of Clinical Supervision Services.

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