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RTW Plus are delighted to be expanding our treatment network RTW + ConneXions to include speciality services such as Neuro Physiotherapy, Neuro OT and Neuro Psychology. We pride ourselves in delivering evidence based and effective rehabilitation services for individuals experiencing challenges related to illness or injury. As a part of our network expansion, we are looking to work with selected specialist providers throughout the UK. Our focus is on building a collaborative partnership wherein the rehab client outcomes take centre stage. Equally as important is the relationship with our providers so we enjoy a mutually beneficial environment that is built on open communication about client services and your organisational requirements. Our network extends across Great Britain and Ireland and comprises individual and independent practitioners as well as organisation with multiple practitioners operating under a single company, as well as multiple clinics. The following form is intuitive and if you are a single practitioner then you only need to complete sections 1 and 2. If you are an organisation with multiple practitioners we would ask that you provide as many details as you would like, or alternatively contact info@rtwplus.com to discuss the best way to include your many locations time efficiently. We look forward to working with you!
1. Your Details
Title
Mr
Mrs
Miss
Ms
Dr
Prof
First Name
*
Last Name
*
Gender
*
Male
Female
Date of Birth
Mobile Phone Number
*
Emergency Contact Number
Email Address
*
Company Name and Company Number
Registered Office Address
Website Address (if applicable)
What is your specialism? (Press ctrl to select multiple items)
Speech and Language
Specialist Dietetics
Physiotherapy – Complex Orthopaedic
Physiotherapy – Neuro
Physiotherapy – Paediatric
Occupational Therapy – Complex Orthopaedic
Occupational Therapy – Neuro
Occupational Therapy – Paediatric
Psychology – Clinical Psychologist
Psychology – Psychotherapist
Psychology – Neuropsychologist
In what environment do you provide services?
*
Clinic Based
Domiciliary
Virtual by Teams of Zoom etc
Other
If other is chosen please explain
2. Registration & Accreditation Details
BABCP
Expiry Date
CSP
Expiry Date
RCOT
Expiry Date
HCPC
Expiry Date
BPS
Expiry Date
EMDR
Expiry Date
GMC
Expiry Date
Other
Expiry Date
Other (2)
Expiry Date
Other (3)
Expiry Date
3. Your Clinics (complete only for clinic based services)
If you are a clinic with multiple practitioners, please add all the practitioners for your clinic who will be taking referrals from us. Please inform us if these details change. If your clinic has more therapists you would like to register, please contact us at rehab@rtwplus.com.
Clinic Name
Clinic Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Is this your home address?
*
Yes
No
Do you provide disabled access?
*
Yes
No
Do you provide parking?
*
Yes
No
Is there a waiting area?
Yes
No
How far are you from a good service on public transport?
On Doorstep
Within a 5-min walk
Within a 10-min walk
More than a 10-min walk
What is the closest mode of public transport to the clinic?
Bus
Train
Tram
What are the clinic opening times?
Weekdays
Evenings
Weekends
Part-time only
Part-time only (Please specify)
Clinic Room Photos
Click or drag files to this area to upload.
You can upload up to 4 files.
Attach clinic room photo(s) both Internal and External. Up to 4 photos. If not submitted with your application it will be required at a later date.
Add another clinic?
Yes
Clinic Name
*
Clinic Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Is this your home address?
*
Yes
No
Do you provide disabled access?
*
Yes
No
Do you provide parking?
*
Yes
No
Is there a waiting area?
Yes
No
How far are you from a good service on public transport?
On Doorstep
Within a 5-min walk
Within a 10-min walk
More than a 10-min walk
What is the closest mode of public transport to the clinic?
Bus
Train
Tram
What are the clinic opening times?
Weekdays
Evenings
Weekends
Part-time only
Part-time only (Please specify)
Clinic Room Photos
Click or drag files to this area to upload.
You can upload up to 4 files.
Attach clinic room photo(s) both Internal and External. Up to 4 photos. If not submitted with your application it will be required at a later date.
Add another clinic?
Yes
Clinic Name
*
Clinic Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Is this your home address?
*
Yes
No
Do you provide disabled access?
*
Yes
No
Do you provide parking?
*
Yes
No
Is there a waiting area?
Yes
No
How far are you from a good service on public transport?
On Doorstep
Within a 5-min walk
Within a 10-min walk
More than a 10-min walk
What is the closest mode of public transport to the clinic?
Bus
Train
Tram
What are the clinic opening times?
Weekdays
Evenings
Weekends
Part-time only
Part-time only (Please specify)
Clinic Room Photos
Click or drag files to this area to upload.
You can upload up to 4 files.
Attach clinic room photo(s) both Internal and External. Up to 4 photos. If not submitted with your application it will be required at a later date. If your clinic has more therapists you would like to register, please contact us at rehab@rtwplus.com.
4. Additional Practitioners
If adding more than 6 additional practitioners, email the details to info@rtwplus.com.
No. of Additional Practitioners
0
1
2
3
4
5
6
Title
Mr
Mrs
Miss
Ms
Dr
Prof
First Name
Last Name
Contact Number
Email Address
Specialism
Physiotherapy – Complex Orthopaedic
Physiotherapy – Neuro & Paediatric
Occupational Therapy
Psychology by Clinical Psychologist
Psychology by Psychotherapist
Neuropsychology
Neuro & Paediatric OT
Years of Experience
Address (if different from clinic address)
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Qualifications
Additional Notes
Title
Mr
Mrs
Miss
Ms
Dr
Prof
First Name
Last Name
Contact Number
Email Address
Specialism
Physiotherapy – Complex Orthopaedic
Physiotherapy – Neuro & Paediatric
Occupational Therapy
Psychology by Clinical Psychologist
Psychology by Psychotherapist
Neuropsychology
Neuro & Paediatric OT
Years of Experience
Address (if different from clinic address)
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Qualifications
Additional Notes
Title
Mr
Mrs
Miss
Ms
Dr
Prof
First Name
Last Name
Contact Number
Email Address
Specialism
Physiotherapy – Complex Orthopaedic
Physiotherapy – Neuro & Paediatric
Occupational Therapy
Psychology by Clinical Psychologist
Psychology by Psychotherapist
Neuropsychology
Neuro & Paediatric OT
Years of Experience
Address (if different from clinic address)
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Qualifications
Additional Notes
Title
Mr
Mrs
Miss
Ms
Dr
Prof
First Name
Last Name
Contact Number
Email Address
Specialism
Physiotherapy – Complex Orthopaedic
Physiotherapy – Neuro & Paediatric
Occupational Therapy
Psychology by Clinical Psychologist
Psychology by Psychotherapist
Neuropsychology
Neuro & Paediatric OT
Years of Experience
Address (if different from clinic address)
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Qualifications
Additional Notes
Title
Mr
Mrs
Miss
Ms
Dr
Prof
First Name
Last Name
Contact Number
Email Address
Specialism
Physiotherapy – Complex Orthopaedic
Physiotherapy – Neuro & Paediatric
Occupational Therapy
Psychology by Clinical Psychologist
Psychology by Psychotherapist
Neuropsychology
Neuro & Paediatric OT
Years of Experience
Address (if different from clinic address)
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Qualifications
Additional Notes
Title
Mr
Mrs
Miss
Ms
Dr
Prof
First Name
Last Name
Contact Number
Email Address
Specialism
Physiotherapy – Complex Orthopaedic
Physiotherapy – Neuro & Paediatric
Occupational Therapy
Psychology by Clinical Psychologist
Psychology by Psychotherapist
Neuropsychology
Neuro & Paediatric OT
Years of Experience
Address (if different from clinic address)
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Qualifications
Additional Notes
5. Service & Costs
Initial Assessment Costs
*
Treatment Sessions Costs
*
Reports Costs
*
Travel Costs
*
Mileage
*
Travel time
*
Other Service Name
Other Service Cost
Other Service Name
Other Service Cost
Other Service Name
Other Service Cost
6. Due Diligence
Lead Clinician CV
Click or drag a file to this area to upload.
Professional Indemnity Insurance
Click or drag a file to this area to upload.
Insurance Name
Amount of Policy
Expiry Date
DBS
Click or drag a file to this area to upload.
DBS Update Number (if applicable)
7. Declaration
I confirm that the information above is accurate to the best of my knowledge and belief. I understand that false information may result in withdrawal or refusal of your registration.
*
Yes
Are you subject to any pending or existing Professional Disciplinary action?
*
No
Yes
Do you have any criminal convictions, other than motoring offences?
*
No
Yes
Submit