Registration Form

The Treatment Network is continually evolving and experienced therapists are invited to join either our Physical Therapies Network or our Psychological Therapies Network. The Networks both operate throughout the United Kingdom and Ireland.

All our therapists are required to be either registered with their appropriate body (e.g. HCPC) or accredited by relevant organisations (e.g. BACP or BABCP).

To register with us please complete the online form below. A member of our team will be then be in touch to complete the registration process.

If you have any queries please contact our office on 0117 962 5017.

Section 1 Your Details

Title (Required)

First Name (Required)

Surname (Required)

Gender (Required)

Date of Birth (Required)

Mobile Phone Number (Required)

Emergency Contact Number (Required)

Email Address (Required)

Secretary Email Address (if applicable)

Please Provide Your Website Address (if applicable)

Section 3 Registration and Accreditation Details

BABCP

Expiry Date

HCPC

Expiry Date

BPS

Expiry Date

BACP

Expiry Date

EMDR

Expiry Date

GMC

Expiry Date

Other

Expiry Date

Section 4 Your Clinics

Please add all the practitioners for your clinic who will be taking referrals from us. Please inform us if these details change. If your clinic has more therapists you would like to register please contact us on the above number following the submission of this form.

Clinic Address (First clinic address)

House Number (Required)

Street Name (Required)

Town (Required)

County (Required)

Country

Postcode (Required)

Is This Your Home Address? (Required)

Disabled Access? (Required)

Parking Available? (Required)

Is there a waiting area?

How far are you from a good service on public transport?

Attach clinic room photo(s) both Internal and External (up to 4 photos. If not submitted with your application it will be required at a later date.)

Add Another Clinic

Clinic Address (Second clinic address)

House Number

Street Name

Town

County

Country

Postcode

Is This Your Home Address?

Disabled Access?

Parking Available?

Is there a waiting area?

How far are you from a good service on public transport?

Attach clinic room photo(s) both Internal and External (up to 4 photos. If not submitted with your application it will be required at a later date.)

Add Another Clinic

Clinic Address (Third clinic address)

House Number

Street Name

Town

County

Country

Postcode

Is This Your Home Address?

Disabled Access?

Parking Available?

Is there a waiting area?

How far are you from a good service on public transport?

Attach clinic room photo(s) both Internal and External (up to 4 photos. If not submitted with your application it will be required at a later date.)

Add Another Clinic

Clinic Address (Fourth clinic address)

House Number

Street Name

Town

County

Country

Postcode

Is This Your Home Address?

Disabled Access?

Parking Available?

Is there a waiting area?

How far are you from a good service on public transport?

Attach clinic room photo(s) both Internal and External (up to 4 photos. If not submitted with your application it will be required at a later date.)

Section 5 Additional Practitioners

Practitioner (First Practitioner)

Title (Required)

Name (Required)

Surname (Required)

Contact Number (Required)

Email Address (Required)

Address (if different from clinic address)

Specialism (Required)

Qualifications

Years of Experience

Additional Information

Add Another Practitioner

Practitioner (Second Practitioner)

Title (Required)

Name (Required)

Surname (Required)

Contact Number (Required)

Email Address (Required)

Address (if different from clinic address)

Specialism (Required)

Qualifications

Years of Experience

Additional Information

Add Another Practitioner

Practitioner (Third Practitioner)

Title (Required)

Name (Required)

Surname (Required)

Contact Number (Required)

Email Address (Required)

Address (if different from clinic address)

Specialism (Required)

Qualifications

Years of Experience

Additional Information

Add Another Practitioner

Practitioner (Fourth Practitioner)

Title (Required)

Name (Required)

Surname (Required)

Contact Number (Required)

Email Address (Required)

Address (if different from clinic address)

Specialism (Required)

Qualifications

Years of Experience

Additional Information

Section 6 Due Diligence

Professional Indemnity Insurance

Insurance Name

Amount of Policy

Expiry Date

DBS / CRB Certificate (If you have one)

Section 7 Declaration

I confirm that the information above is accurate to the best of my knowledge and belief. I understand that false information may result in withdrawal or refusal of your registration. (Required)

Are you subject to any pending or existing Professional Disciplinary action? (Required)

Do you have any criminal convictions, other than motoring offences? (Required)

Registration Form

Section 1 Your Details

Section 2 Professional Details

Section 3 Registration and Accreditation Details

Section 4 Your Clinics

Section 5 Additional Practitioners

Section 6 Due Diligence

Section 7 Declaration

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