Small Group Supervision - Dr Eva Balint

 



Email: nswipp4@bigpond.com Website: www.nswipp.org ABN 1700 1558 201
Small Group Supervision
Application Form
Name: ___________________________________________________________________________
Professional Qualifications/Organisation membership:______________________________________
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Home Address:_____________________________________________________________________
Work Address:_____________________________________________________________________
Telephone No:____________________________
Preferred mobile phone contact no:___________________________
Preferred email address:_____________________________________________________________
Current Professional Indemnity Insurance:_______________________________________________
Current Professional Work experience:__________________________________________________
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Psychodynamic Psychotherapy Work experience:_________________________________________
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Past Supervision Experience:_________________________________________________________
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Personal Psychotherapy Experience:___________________________________________________
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Goals/Areas of interest:_____________________________________________________________
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