APPLICATION FOR ADVANCED MEMBERSHIP

Step 1 of 7 - Personal Details

14%

Please complete all sections

Please advise what date you would like to book for your assessment. Availability can be found https://www.babicm.org/peer-review-calendar/

Assessment Date

Name(Required)

Title Forename Surname

Job Title(Required)

Professional Qualifications(Required)

(please tick below & attach photocopy evidence)

Chartered Psychologist

Doctor

Nurse

Occupational Therapist

Physiotherapist

Social Worker

Speech & Language Therapist

Other

Please Specify Other(Required)

Membership of Professional Bodies and registration number for each(Required)

If you are applying for advanced assessment review to become an advanced practitioner, you MUST have one of the seven qualifications listed above, and your Professional Body MUST be actively responsible for monitoring your Continued Professional Development. You will be required to bring your CPD folder to the peer review for discussion.

DBS Enhanced Disclosure: It is essential that all case managers working with vulnerable adults & children must obtain an enhanced disclosure.

I confirm that I have PVG (Scotland) or DBS Enhanced Disclosure(Required)

Confirm

Employing Organisation:(Required)

Sole practitioner

Primary Health Care Trust

Insurance company

Private Rehabilitation unit

Case Management Company

Social services

Care Agency

Healthcare organisation

Charitable organisation

Other

Please specify other(Required)

Organisation name & Address for contacting you(Required)

(NB If successful this is what will be displayed on the BABICM website)

Tel(Required)

Fax

Email Address(Required)

Website

In which working environment do you currently practice?(Required)

Hospital

Community

Residential Care Home

Rehabilitation Unit

Vocational

Other

Please Specify Other(Required)

How many clients do you actively case manage?(Required)

If you supervise, how many case managers? (please indicate)(Required)

What date did you commence active case management practice(Required)

MM slash DD slash YYYY

What are the average number of hours per week you practice as a Case Manager?(Required)

0 to 8

8 to 20

20 plus

Have you completed the equivalent of 3500 hours (3 years full time working) as a brain injury case manager?(Required)

Yes

In line with best practice, all practitioners are expected to have a clinical supervisor with experience in brain injury and complex case management.

Do you have a mentor/clinical supervisor?(Required)

Yes

Please provide his/her name, qualification and contact details:(Required)

Unfortunately you are not currently eligible to apply for Advanced BABICM Membership.
Please contact the BABICM office at secretary@babicm.org

All practitioners working in the UK must hold a current insurance policy covering them for malpractice and public liability, endorsed for case management.

I confirm I am covered by an insurance policy for malpractice and public liability.(Required)

I Confirm

Please provide us with two written references, these can be emailed to the BABICM administrators at secretary@babicm.org (a sample letter is down loadable to help you request a reference):

1) From your current employer/supervisor.
2) From a professional referee to whom you have provided case management services, together with details of the work undertaken.

Please note, the date of the references must be within 2 months of the date of the signature of the applicant on this application form. If circumstances lead to the review being postponed for over 18 months, it may be necessary to obtain new references.

Download Sample Letter Download Sample Letter

The cost of the advanced membership review is £200.

Cancellation

The BABICM policy states that applicants who wish to cancel or postpone a review once the date has been confirmed by the administrators will be issued with a 50% cancellation fee up to 30 days before the assessment date. Any cancellations after 30 days will result in no refund.

I, the undersigned, hereby apply to for Advanced membership of The British Association of Brain Injury & Complex Case Management Limited. I agree to be bound by the BABICM Competency Framework. A copy of which I received from BABICM and have retained for record purposes. I grant permission for my membership records to be held on computer for the purposes of handling membership, publishing the members’ register and mailing out membership information.

Name(Required)

Date(Required)

DD slash MM slash YYYY

Advanced Membership Review(Required)

Price:

Total

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Debit/Credit Card

Paypal

Pay by invoice

Payment Method

MasterCard

Visa

Supported Credit Cards: MasterCard, Visa

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