Practitioner application form

CHHC t/a Cheltenham Holistic Health Centre: Practitioner Application Form Please fill out the form below and return it to: Practice Manager, CHHC, Camargue House, 32 Wellington Road, Cheltenham, Glos GL52 2AG Name ..................................................................................................... Address ............................................................................................................................................ ........................................................................................................................................................... ................................................................................................ Postcode........................................... Tel ........................................................ email................................................................................... Mobile .................................................. Age..................... male/female Therapy(s)........................................................................................................................................ Training courses completed .......................................................................................................................................................... .......................................................................................................................................................... .......................................................................................................................................................... Qualifications & dates .......................................................................................................................................................... .......................................................................................................................................................... .......................................................................................................................................................... Practice experience .......................................................................................................................................................... .......................................................................................................................................................... .......................................................................................................................................................... Name of Insurer ............................................................................................................................... .......................................................................................................................................................... Which day(s) do you prefer to work? Mon Tue Wed Thurs Fri Sat Sun What specific requirements do you need for your therapy? (type of couch, no couch, 2 chairs only etc.) .......................................................................................................................................................... .......................................................................................................................................................... DECLARATION OF FITNESS TO PRACTISE Do you currently have or have you ever had any court cases, insurance claims or ethics claims taken against you or that you have been involved in? YES/NO If yes please give details on a separate sheet of paper. Do you have any current or recent health problems that may affect your ability to practise? YES/NO If yes please give details on a separate sheet of paper. Are you on any medication that may affect your ability to practice ? YES/NO If yes please give details on a separate sheet of paper. Are you aware of any health issues that may affect your ability to continue to practise in the next year? YES/NO If yes please give details on a separate sheet of paper. Signed and Dated ...................................................................... date .........................