Graduate Diploma In Mental Health (GDMH)
Intake 2017 - 2018
APPLICATION FORM
Please tick the appropriate boxes accordingly. * Delete where applicable
(A)
PERSONAL PARTICULARS
Name (as in NRIC/Passport):
Residential Address
2 coloured
passport-sized
photographs
required.
:
Postal Code:
NRIC / Passport Number:
(Please attach a copy of NRIC (front & back) with this application)
Marital Status: Single / Married / Divorced*
Citizenship
Gender: Male / Female*
Clip the SECOND
photograph
together with the
application form.
: Singaporean / Others* (please specify):
Place of Birth :
Date of Birth:
Race :
Paste ONE
photograph in this
space.
Email Address (must be legible) :
Telephone (Home):
Mobile Phone Number:
Name of Next-of-Kin:
Relationship:
Address of Next-of-Kin:
(B)
PRACTICE INFORMATION
MCR Number
:
Medical Registration Type
: Full / Conditional / Temporary*
Type of Practice
Government
NHG
SingHealth
Locum
Private – Group
Private – Solo
:
Hospital / Polyclinic / Clinic Name
Year of SMC Registration:
Others:
:
Hospital / Polyclinic / Clinic Address :
Postal Code
:
Telephone (Office)
:
Please indicate your preferred mailing address with a tick:
Fax (Office)
:
Residential Address
Practice Address
1
(C)
Other Information
Degrees / Diplomas Awarded (Attach a separate sheet if necessary)
Photocopies of the certificates are required
Qualification
Year
Employment History – List all postings since Medical Officer (Attach a separate sheet if necessary)
Position Held
Department in Hospital /
Medical Group / Practice
From
(Month / Year)
To
(Month / Year)
Remarks
(if any)
2
(D)
Mode of Study
Please tick where applicable.
Participants who have attended “Introductory Training to GPs” by IMH will sit for a proficiency test to
determine eligibility for Module 1 exemption.
1. Have you attended “Introductory Training to GPs” (conducted by IMH)?
Yes. (Please proceed to option 2b)
No. (Please proceed to option 2a)
2. I would like to:
st
a.
Apply for full course, payable fee: $6,694.50 (early bird rate for submission to IMH by 31 May 2017)
st
or $6,837.50 (application submitted to IMH from 1 June 2017 onwards)
(Applicant shall pay an exam admin fee of $600 to NUS upon successful enrolment into GDMH. NUS will notify
applicant via email to make this payment online in due course.)
b.
Apply for full course with Module 1 exemption, payable fee: $5,624.50 (early bird rate) or
$5,767.50 (application submitted to IMH from 1st June onwards)
(Applicant shall pay an exam admin fee of $500 to NUS upon successful enrolment into GDMH with exemption
from module 1. NUS will notify applicant via email to make this payment online in due course. Applicants who
select this option are required to pay the payable fee of either $6,694.50 (early bird rate) or $6,837.50
(application received by IMH from 1 June onwards) during registration. Once application for exemption from
Module 1 is approved, a refund of $1,070 will be made.)
Note: MOH sponsors 80% of the course fee (GST inclusive). MOH’s subsidy will be reimbursed to all eligible applicants
upon successful completion of the final exam.
(E)
Declaration
1. I hereby make an application to the Graduate Diploma in Mental Health (GDMH) and declare all information I
have provided on this application form is complete and correct.
2. I acknowledge that my application for enrolment is subject to admission criteria and examination eligibility as
advised by DGMS and IMH, both of which have the power to impose conditions.
3. I agree to participate in the Mental Health GP Partnership Programme upon completing the course.
4. By signing this form, I acknowledge that I have read and agree to abide by the Terms and Conditions stated
under „Important Notes‟.
5. I declare that I am a practicing doctor.
6. I declare that I am free from any legal proceedings, investigation or disciplinary action by the Singapore Medical
Council.
Signature of the Applicant: ___________________________
Date: ___________________
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(F)
Terms & Conditions
1. The applicant shall adhere to requirements stated in the GDMH Programme Guide.
2. The applicant shall abide by the Non-Disclosure & Security Awareness Agreement.
3. The applicant shall abide by the rules and regulations governing use of IMH premises and library facilities.
4. The applicant shall adhere to guidelines for course work completion, such that all criteria for examination eligibility
are met.
5. The applicant should be free from any legal proceedings, investigation or disciplinary action by the Singapore
Medical Council (SMC). If there are legal proceedings, investigation or disciplinary action pending against the
applicant, this must be informed to IMH.
6. Strictly no refund of fees if there is a notice of withdrawal from GDMH or any of its modules upon course
commencement. A written notice of withdrawal must be submitted for consideration.
7. IMH and/or NUS may, at their discretion, vary terms and conditions governing GDMH at anytime, without notice.
I acknowledge that my enrolment to GDMH is subject to the admission criteria and examination eligibility as advised
by DGMS and IMH, both of whom have the power to impose conditions. I accept enrolment to GDMH and hereby
agree to abide to all Terms and Conditions.
Name
:
MCR number :
Signature
:
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Please send the completed application form (with two photographs attached), a photocopy of the certified true copy
medical degree certificate, photocopy of the certified true copy supporting certifications and a photocopy of your NRIC
(front and back) together with cheque payable to
“Institute of Mental Health”.
Mail to: Buangkok Green Medical Park, 10 Buangkok View Singapore 539747
Attention: Ms Nirhana Japar / Ms Tan Yen Nee (Education Office)
1) What is/are your objective(s) in taking up the Graduate Diploma in Mental Health (GDMH)?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
2) How did you find out about the Graduate Diploma in Mental Health (GDMH)?
SMA Website
GP Workshop
SMA Newsletter
IMH Website
Mailer Poster
Singapore Medical Journal
NUS Website
Newspaper Article
SMA email blast
MOH Website
Friends
Others: _____________________
IMPORTANT NOTES
1. Fees are applicable as follows:
st
Registration Fee
(non-refundable)
$107 (Early bird rate if application received by IMH by 31 May 2017)
st
$250 (Registration fee received by IMH from 1 June 2017 onwards)
$6,420
Course Fee
(for all 6 modules)
(MOH subsidizes 80% of the course fee. Course fee will be reimbursed to all candidates
upon successful completion of the final exam)
Book Fee
Module 1
$70 (“Essential Guide to Psychiatry”)
Book Fee
Module 2
$15.50 (“Delusions, Possession or Imagination?”)
Book Fee
Module 5
$82.00 (“A Primer of Child and Adolescent Psychiatry”)
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2. Please ensure that copies of your medical degrees/academic qualifications are stamped „certified true copy‟
before mailing your application. The supporting documents should be stamped certified true copy and signed
by any of the following parties:

Notary public (lawyer)

Issuing university or school and

Head of the Department bearing his official designation, department and signature.
However, if you are submitting your documents in person to IMH, the GDMH administrators will be able to stamp
„Original Sighted‟ and sign on your supporting documents. Please present the original versions for verification
purposes.
3. Deferment
A 10% administrative fee per module ($107 per module) will be payable by candidates who wished to defer any
module. Please be informed that this fee is non-refundable. Candidate is required to inform the GDMH
administrator on the request and fill up the deferment form at least 3 months before the module. The request is
subject to Programme Director‟s approval, on a case-by-case basis.
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Information Access Authorisation Form
By signing this GDMH Information Access Authorisation Form, you agree that Institute of Mental Health may collect,
use and disclose your personal data, as provided in this form, or (if applicable) obtained by our organisation as a
result of your training here, for the following purpose in accordance with the Personal Data Protection Act 2012 and
our data protection policy (available on our website: https://www.imh.com.sg/pdp-notification/):
(a) the processing of GDMH course registration;
(b) the administration of the GDMH course;
(c) Sharing of information with Mental Health GP-Partnership Programme (GPPP) for recruitment of GPs into the
programme; and
(d) Allow/ Disallow (circle one) sharing of the selected information* with healthcare agencies such as MOH,
AIC and VWOs for the purpose of referring of patients to GDMH-trained GPs.
*For (d), please select the type of information that you are agreeable to disclose:
 Name of Doctor
 Name of Clinic
 Clinic Address
 Clinic phone and fax number
 Email Address
You have the right to revoke this authorization at any time, provided you do so in writing. If you revoke your
authorization, we will no longer use or disclose information about you for the reasons covered by your written
authorization, but we cannot take back any uses or disclosures already made with your permission.
Please visit our website at https://www.imh.com.sg/pdp-notification/ for further details on our data protection policy,
including how you may access and correct your personal data or withdraw consent to the collection, use or disclosure
of your personal data.
Name
: __________________________
Signature
: __________________________
Date
: __________________________
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Withdrawal of Authorisation Clause
You have the right to revoke this authorization at any time, provided you do so in writing. Revoking the authorization
means that we will no longer use or disclose information about you for the reasons stated in your written authorization.
However, we cannot take back any uses or disclosures already made with your permission. To revoke this
authorization, please send an email or a written statement to GDMH Administrator at [email protected] or mail
to:
GDMH Administrator
Education Hub
Institute of Mental Health
10 Buangkok View
Buangkok Green Medical Park
Singapore 539747
In the letter, please include the following:
 the recipient of the information identified in the authorization;
 state that you are revoking this authorization; and
 the date you signed this authorization
Please visit our website at https://www.imh.com.sg/pdp-notification/ for further details on our data protection policy,
including how you may access and correct your personal data or withdraw consent to the collection, use or disclosure
of your personal data.
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Note:
All fees quoted are inclusive of 7% GST.
NUS & IMH reserve the right to make any amendments to the course structure and fees without any prior notification
or whatsoever to the parties involved.
Refund Policies
Request for withdrawal must be made in writing to the Programme Director. Policies for course fee refund are as
follows:
1. 100% refund if the request for course withdrawal is made in writing more than 30 calendar days before course
commencement.
2. 90% refund if the request for course withdrawal is made in writing no less than 15 calendar days before course
commencement.
3. Strictly no refund of fees if request for course withdrawal is less than 15 calendar days before course
commencement and/or after the course commences.
Note: Calendar days include Saturday and Sunday.
All feedback and correspondences should be addressed to:
Ms Nirhana Japar (Executive, Education Office) | Ms Tan Yen Nee (Senior Executive Assistant, Education Office)
Institute of Mental Health
Buangkok Green Medical Park
10 Buangkok View, Singapore 539747
Telephone
: 6389 2831 (Nirhana Japar) | 6389 2246 (Tan Yen Nee)
Email
: [email protected] | [email protected] | [email protected]
Website
: www.imh.com.sg
Fax
: 6389 2834
*
The date is based on the day when IMH receives the letter of withdrawal.
**
Calendar days include Saturday and Sunday.
(H)
For Official Use Only
Fee Paid
: S$______________
Cheque Number
: ________________
Acknowledgement Date
: _________________
Official Receipt Number
: ________________
Checked By
: _________________
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Degrees / Diplomas Awarded (Additional copy)
Qualification
Year
10