Therapist Registration test

Professional - Registration Form

Title

First name*

Last name*

E-mail*

Password*

Confirm Password*

Mobile number*

Profession*

Registered qualifications*

HPCSA/SACSSP registration number*

Practice number (13 digit)*

Rate per hour*

ID/Passport number*

Social Media

I hereby grant permission to Headroom to promote my profile via social media in line with the HPCSA Ethical Guidelines on Social Media.

Copy of ID/Passport*

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Ethics and Code of Conduct*

I confirm my compliance with the ethical guidelines for good practice as prescribed by the HPCSA/PsySSA/SACSSP and/or any other rules and regulations applicable by virtue of my professional registration.

I have read and accept the Privacy Policy and the Acceptable Use Policy

Therapist Agreement and Headroom.co.za Fees Schedule*

I have read and accept the Therapist Agreement and the Headroom.co.za Fees Schedule.

Headroom service level*

Certificate of status*

I acknowledge that Headroom may, at its sole discretion, request my certificate of status from the relevant professional body.

Only fill in if you are not human

Professional - Registration Form

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