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Title
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Forename
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Department/Team Name:
Address
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Post Code
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Membership Level
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Individual
Team up to 4
Team up to 8
Team up to 15
Team up to 20
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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
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Service Provision
Intensive short term therapy
Long term maintenance therapy
Other
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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
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Any Current Project/Research
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