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Palmeira Practice Enquiry Form

Palmeira Practice logo
Palmeira Practice
This is a first stage enquiry form for any counsellor or psychotherapist who is interested in joining the Palmeira Practice. In order to progress your application to work with us, we'd appreciate if you could take a few minutes to tell us about yourself and your practice. This form takes about 10 - 15 minutes to complete. When this has been received we will get in touch with any questions and will invite suitable applicants to complete our full Membership form and to provide details for the Practice website. The form will save if you wish to complete it in more than one session.

First Name

Last Name

Email

Phone Number

We only accept practitioners who are able to offer some in-person evening sessions. Do you agree?

We only accept practitioners who are able to offer some in-person evening sessions. Do you agree?
A
B

Tick ALL the times you will be available for referrals (not your current availability, but your general working hours).

AM (8am - 12pm)
PM (12pm-4pm)
5pm
6pm
7pm
8pm
Monday
Tuesday
Wed
Thurs
Friday
Saturday
Sunday

Please say which of the above time slots are (a) in-person only (b) online only (c) could be either

What client groups are you qualified to, or experienced in, working with?

What client groups are you qualified to, or experienced in, working with?
A
B
C
D
E
F
G

What top 3 specialisms would you want to offer if you were a member of the Practice?

What counselling qualifications do you currently hold?

When did you first qualify as a counsellor or psychotherapist?

How many years experience do you have as a practising counsellor/ psychotherapist since qualifying? In order to join the Palmeira Practice you will need to have 2-3 years post-qualification experience of working with clients.

Which membership body are you a member of?

What are your fees for individual sessions (& couples if you work with couples)

Are you accredited with your membership body

Are you accredited with your membership body
A
B

What kind of therapy service do you want to offer to clients referred by The Palmeira Practice. Please choose all that apply.

What kind of therapy service do you want to offer to clients referred by The Palmeira Practice. Please choose all that apply.
A
B
C

The Palmeira Practice does not accept applications from therapists working online only. We will consider applications from online-only therapists if they are working in a specialism the Practice needs to fulfil client demand. Please confirm you understand and agree to this.

The Palmeira Practice does not accept applications from therapists working online only. We will consider applications from online-only therapists if they are working in a specialism the Practice needs to fulfil client demand. Please confirm you understand and agree to this.
A
B

Where is your consulting room? Please give (a) the name and address of the Practice you belong to, (b) say if your rooms are independent and not part of a Practice, or (c) if you are working from home.

You will be asked to provide at least one good quality photo of the therapy room(s) you work from (or usually work from) for your profile page on the Palmeira Practice website. Please confirm you are willing to do this.

You will be asked to provide at least one good quality photo of the therapy room(s) you work from (or usually work from) for your profile page on the Palmeira Practice website. Please confirm you are willing to do this.
A
B

Palmeira Practice membership is limited in number. We believe this offers most therapists the best chance of getting a good number of referrals. We do not charge a monthly fee; we charge when you get a referral and the referral fee is the only income we receive. For this reason therapists who take less than 4 referrals from us per year may be asked to leave the Scheme, so their place can be given to someone else. Please confirm your understanding of this.

Palmeira Practice membership is limited in number. We believe this offers most therapists the best chance of getting a good number of referrals. We do not charge a monthly fee; we charge when you get a referral and the referral fee is the only income we receive. For this reason therapists who take less than 4 referrals from us per year may be asked to leave the Scheme, so their place can be given to someone else. Please confirm your understanding of this.
A
B

If you have a website please give the address here. If you don't have a website please link to a directory listing or other online presence.

And lastly, why do you want to join the Palmeira Practice? You can also use this answer block to tell us about anything else.

Thank you for completing this form.
Please press the submit button below. Please be aware you will not be sent a confirmation email or a copy of your form.