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Parks Inner Child TherapyTrainingWorkshopsAbuse InformationFinding a TherapistThe FoundationPenny ParksFAQTalking to UsUseful Links Online Application Form Personal Information Surname Forename Title Full name as you would like it to appear on your certificate Home Address Town County/State Country Postal/ZIP code Home Telephone Work Telephone Mobile Telephone Email Counselling/Therapist Training or Qualifications (Place, type & duration): Membership of Professional Bodies : Practical Therapy/Counselling Experience (present or most recent experience first) Name, Address, Tel Position & Responsibilities From/To Reason for Leaving Personal Issues Have you experienced abuse during your childhood? (Tick all that apply) None Sexual Physical Emotional Have you resolved your past abuse issues? None Some Half Most All What method/action did you use towards resolution of your past abuse issues? Have you had treatment for any mental illness? Yes No If so give brief details: Do you have any criminal convictions? Yes No Are there any current criminal proceedings against you? Yes No If either answer is 'yes' please give brief details: Course Preferences Please give the Starting date of the training you are applying for Please select the location of the training you are applying for Berkshire Essex Suffolk Teeside If you have attended any PICT Course or Workshop, please give the trainer's name and date of the course/workshop. Where did you learn of the PICT Advanced Practitioner training? References Please give information of two professional references. Reference 1   Name Organisation Position Telephone Reference 2   Name Organisation Position Telephone Confirmation I confirm that the information given above is true and accurate