Leadership Training Pathway Application Form

Items marked * are required

Your Name *

Date of birth *

Work address *

Mailing address if different *

Email *

Work Phone

Home Phone

Mobile Phone

Current occupation *

(include professional roles, place of work, and scope of work)

How long have you worked in this capacity? *

Professional Qualifications *

Membership of Professional Associations and Colleges *

Professional registration details *

Registering body *

Registration number *

Name of Professional indemnity insurer *

History of Balint group involvement

(e.g. ongoing groups, short courses, Balint Intensives)

Details of frequency and duration of meetings

Duration of membership of the group(s)

Names of leaders

Group experience, as a participant, other than in Balint groups.

(Please list all of the groups in which you have participated).

Group leadership experience in Balint Groups

Group leadership experience in Other Groups

Please attach the following documents with your application (PDF or document format e.g. PDF DOC ODT):

Your curriculum vitae

Letter from a BSANZ accredited leader supporting this application

(Or ask a registered professional colleague to send a reference supporting your application directly to admin.bsanz@bigpond.com)

Photocopy of you professional indemnity certificate

I have read and accepted the requirement that Documents A, B and D (available through links on the Accredited Leadership page) will be completed and forwarded to the Accreditation Committee when my application for leadership training is accepted *

Please click on Send and be patient, uploading large files may take some time.