Non Clinical Associate Membership

Part A: Personal Details

Title:

First Name(S):

Surname:

Email:

Telephone:

House number:

Address:

Town:

Post Code:

Employer: (Or if retired or self-employed nature of business)

Job Title:

Reason for interest in membership:

Have you previously held UPCA Membership?

If YES what was your membership number ?

Yes No

Have there ever been any complaints made against you in regard to your clinical work:

If YES please provide the details

Yes No

Terms and Conditions

UPCA Non-Clinical Associate Membership:

In order to become a Non-Clinical Associate Member of UPCA, members must agree to the following conditions:

You have an interest in psychotherapy or psychotherapeutic counselling and wish to support UPCA
You confirm that you are not currently engaged in clinical practice within psychotherapy or psychotherapeutic counselling
You must advise UPCA of any complaints or convictions made against you
You will pay the annual subscription fee
You will notify UPCA if your contact details change

In addition, UPCA Non-Clinical Associate Members confirm they understand that;

You cannot claim to be a clinical member of UPCA or imply any kind of accreditation by UPCA
You must inform UPCA of any information that is relevant to the individual's terms of non-clinical membership
You are not entitled to vote at any UPCA elections
UPCA will not have regulatory responsibilities for its individual non-clinical associate members.

DECLARATION:

I declare that my application form contains only true information. I understand that UPCA may make enquiries as they consider necessary to verify any information given. I understand that if any incorrect, incomplete or plagiarised information is discovered, my application/renewal may be invalid and UPCA has the right to withdraw my application. I understand that my membership of UPCA (and any associated UKCP membership) is dependent upon remaining in membership of UPCA.

MEMBER SIGNATURE / E-SIGNATURE Signature to be typed, digital signatures are not accepted

DATE

Choose Your Payment Method

Non Clinical Associate Membership Fee: GBP 23.00

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Non Clinical Associate Membership Fee: GBP 23.00

If you prefer to pay by bank transfer, please make your payment as soon as possible after submitting your form, as we cannot process your application or renewal until payment is received.

For UK payments, transfer to:

Account Title UPCA
Account Number 40241253
Sort Code 20-35-27

For international payments in GBP £:

SWIFTBIC BUKBGB22
IBAN GB05 BUKB 2035 2740 2412 53

Please email your payment receipt to administration@upca.org.uk after payment to expedite processing.
Please include your membership number & surname in your payment reference to enable us to trace your payment.