Apply for the CICS Practitioner Certificate in Contemporary Intimate Partner Therapy

To apply for the CICS Practitioner Certificate in Contemporary Intimate Partner Therapy please complete the form below.

The form will expand as you add content. Please provide as much detail as possible. Incomplete forms will not be accepted.

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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

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Others

Address

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

Professional Training

Please detail all relevant qualifications including: Date, Qualification, Grade and Accrediting Body.

Relevant Qualifications*

Relevant Work Experience

Please detail all voluntary or paid work related to the field of counselling and psychotherapy, sex, sexual health and relationship support.

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

Work Experience*

Eligibility

Please detail how you meet the course entry requirements.*

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 include the details of two professional referees.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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for the Practitioner Certificate in Contemporary Intimate Partner Therapy.