BARNET COUNSELLING ASSOCIATION
The Association of Primary Care Counsellors in Barnet

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APPLICATION FOR MEMBERSHIP

Name ______________________________________________________

Address ____________________________________________________
___________________________________________________________

Phone ________________________    Fax ________________________
Email ______________________________________________________

Name and address of Barnet Practices where you work as a counsellor (also name of lead GP please)

1._________________________________________________________
   _________________________________________________________

2._________________________________________________________
   _________________________________________________________

3._________________________________________________________
   _________________________________________________________

How many counselling hours per week are you paid for at each practice?
1._________________    2._______________    3.__________________

It is ESSENTIAL that you enclose
1. A copy of accreditation or registration certificate.
2. The annual subscription for membership of BCA (currently £15).

Are you accredited by the BACP? ______     Acc No: _________________

Are you registered by the UKCP? ______     Reg No: _________________

Equivalent accreditation? (please give details) ______________________
__________________________________________________________

Do you have professional insurance? Yes/No (please delete)

Whose Code of Ethics do you adhere to? __________________________

Additional information

Is it OK for us to share your address, home phone number and surgeries with other BCA members on our address list? Yes/No (please delete)

Would you like to be added to our list of BCA members willing to take private referrals
(mainly for use by GPs)? Yes/No (please delete)
(if yes, please let me know your counselling address)

Would you like to be added to our list of BCA members offering supervision? Yes/No (please delete)

Please sign this declaration.
The information I have given is to the best of my knowledge correct. I enclose copies of relevant documents and the annual subscription made payable to Barnet Counselling Association.
Signed ___________________     Date _____________________

Please make sure you have completed all sections of your application form and return to June Epstein, BCA Membership Secretary, 1 Cyprus Gardens, London N3 1SP Phone: 020 8346 6082