Register

                        Fields marked * are required

Title
Surname	*
Forename	*
Organisation
Department/Team Name:
Address	*
Town	*
County	*
Post Code	*
Telephone (Daytime)	*
E-mail	*
Required Username	*
Required Password	*
Membership Level	Please Select Individual Team up to 4 Team up to 8 Team up to 15 Team up to 20 *

Please tick all boxes applicable to your service - More than one box can be ticked as required

Client Group Age

Under 16    17 - 64     65 and over

Health Groups

Mental Health  Physical & Sensory Disability  Learning

Population of Area Served

Inner City     Urban     Rural

Skill Mix: Whole time equivalent

Physiotherapist     Clinical Psychologist

Occupational Therapist     Counsellor

Speech & Language Therapist     Nurse

Rehabilitation Assistant      Chiropodist

Doctor     Dietician     Administrator

Social Worker

Other Itemise with commas

Service Provision

Intensive short term therapy

Long term maintenance therapy

Other Itemise with commas

Do you allow self referral?

Yes    No

Invoice Required?

Yes    No

Invoice requested to raise cheque for membership - if requested, you must provide an ORDER NUMBER from your procurement department.

Outcome Measures Used - Itemise with commas

Any Current Project/Research - Free Text

Please type the code shown in the image

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