Apply for The CICS Advanced Diploma in Psychosexual & Relationship Psychotherapy

To apply for the CICS Advanced Diploma in Psychosexual & Relationship Psychotherapy please complete all applicable fields below.

Please complete this application form in full and in detail so that we can fairly assess your suitability for this course of study. If you have any questions, please contact us.

* Asterisk indicates required fields.

Personal Information

First Names*Preferred Name*Surname/Family Name*Gender IdentityPronoun(s)Date of Birth (dd/mm/yyyy)*Country of Birth*Nationality*Mobile Phone Number*Email Address*Website

Social Media Links

Twitter/X

Facebook

Others

Address

Address Line 1*Address Line 2Town/City*Post/zip Code*Country*

Professional Body Membership

Please include organisation, level and membership number.

Professional Body Membership(s)*

Education

Please list all qualifications gained since age 18 including Date, Qualification, Subject and Grade.

Educational Qualifications*

Professional Training

Please detail all qualification level trainings related to psychotherapy, counselling, psychosexual and relationship therapy and all significant CPD’s including Date, Qualification, Grade and Accrediting Body.

Relevant Qualifications*

Relevant Work Experience

Please detail all work, paid or voluntary, related to the field of counselling and psychotherapy and/or relating to the themes of sex and relationships.

Include dates (from-to) and roles/responsibilities.

Work Experience*

Employment History

Please detail your current and past work roles including to/from dates.

Employment History*

Clinical Practice

Please detail how many hours of clinical practice you currently have, your therapeutic modality and the client presentations you currently work with.*

DBS

Do you have a current DBS certificate?*

Criminal Convictions

Do you have any criminal convictions?*

Group Dynamics

How would you describe your experience of working in groups? What role do you tend to take? What, if anything, do you find difficult about learning groups?*

Personal Statement

Please state your reasons for wanting to undertake this specific course of study.*

Access Needs

Please let us know of any formal diagnoses you have that may affect your learning and any associated access needs.

Emergency Contact Details

First Name(s)*Surname/Family Name*Address*Mobile Phone Number*Relationship to you*

Referees

Please provide details of two professional referees, preferably your supervisor/someone connected to therapeutic practice and a past tutor.Referee 1: Name*Referee 1: Job Title*Referee 1: Email Address*Referee 1: Phone Number*Referee 2: Name*Referee 2: Job Title*Referee 2: Email Address*Referee 2: Phone Number*How did you hear about CICS? Social media, Google, told by a colleague/friend etc.*

By submitting this form, you confirm that the information on this form is correct, to the best of your knowledge and wish to submit your application.

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