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71 Lower Baggot Street

Dublin 2, D02P593

E: info@iacat.ie
T: 353 (87)9921746

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MEMBERSHIP APPLICATION

Choose Discipline Of Your Application * Select Membership Type *

PERSONAL DETAILS First Name * Surname * Personal Email * Personal Phone * Organization name * Addr (Line1) * Addr (Line2) City/Town/Village * County * Postcode Country

Are you applying from an over seas college? YES NO

MEMBERSHIP DATA Name of National Professional Association: Full title of course as named by the degree awarding authority: Degree & Grade obtained: Date of commencement & completion: Name & Address of University, institute, college or other degree awarding authority: Contact details of course director (name, telephone, email): Course content transcript details requiredplease upload Choose File Supervised clinical placement including hours completedplease provide dates and names of placements and supervisors with their qualifications and signatures. Please upload letter from supervisor(s) Choose File Personal therapy hours undertaken during and/or after course qualificationPlease provide dates and names of therapists with their qualifications and signatures.
Please upload letter from therapist(s) confirming hours completed * Choose File Therapeutic group work (group process) hours undertaken. please upload letter from group process therapist(s) * Choose File Experiential components of trainingplease provide course descriptions Theoretical components: Module titles & hours completedplease provide course descriptions Continual Professional Developmentunless qualified less than two years before applying to IACAT for registration, please provide details of CPD since qualification/ graduation.

MEMBERSHIP DATA Title of your Masters/Course of Study * College / University * A copy of your Student Card or Insurance Certificate is required Choose File Upload Your Masters Certificate Choose File

Are you a supervisor?

Title of Supervisor Course College / University Upload Your Completion Certificate Choose File Add to IACAT Supervisor Register

Other Professional Memberships Current or Previous Statutory Registrations / Memberships . e.g. CORU, HCPC

PUBLIC REGISTER Add to IACAT Website Therapist Register

Specialises in Locations/Counties you service Practice Address Practice Phone Practice Email Practice Website Brief Bio Sessional work Private Referrals

EMPLOYMENT/SKILLS PROFILE HSE Employee (PAYE) Private Practice Children/Adolescence Adults Groups Family Please Upload Your Insurance Certificate Choose File Educational Services Primary Secondary Third level Gov Health Services Adults Child/Adolescence Residential Care Hospitals Clinics/GPs Elderly Care Palliative Care ABI Other Forensic Services Prisons Probation Addiction Services Alcohol/Substance Gambling Other Disability Services Physical Intellectual Learning Other Voluntary Charities Social Enterprises Other

Have You Ever Had A Complaint In Your Proffesional Pracice YES NO

What was the name of the organisation who dealt with the complaint?

I accept IACAT Code of Ethics of membership

Sign up to the iacat newsletter and keep up to date withthe latest news and events.

MEMBERSHIP APPLICATION

Sign up to the iacat newsletter and keep up to date with
the latest news and events.