SWARTHMORE CENTRE

LEVEL 2 CERTIFICATE IN COUNSELLING SKILLS APPLICATION FORM Sept 2017

Any information given in this form will be shared within the counselling team ONLY.

Please indicate whether daytime or evening:
PERSONAL DETAILS
Surname:
Title:
Forename (in full):
Preferred name:
Date of birth:
Nationality:
Country of birth:
Home address: / Address for correspondence (if different):
Home telephone number:
Mobile number:
E-mail address:
COMPLETED APPLICATION FORMs AND REFERENCES SHOULD BE posted or emailed TO:
Catherine Wray
Counselling Department Tel: 0113 243 7987
Swarthmore Education Centre Fax: 0113 243 4726
2-7 Woodhouse Square, Email:
Leeds
West Yorkshire
LS3 1AD Deadline: 31/07/17

EDUCATION AND QUALIFICATIONS

/
School, College, University or educational establishment / Dates
From To / Qualifications gained or being studied for / Date obtained result and grade /
PAST EMPLOYMENT HISTORY
This section is for brief details about your past employment history. Please include any part-time, casual and voluntary work undertaken. See below for current employment. /
Dates
From - To / organisation name, address and telephone number: / Position held and brief description of duties /
RELEVANT COUNSELLING TRAINING /
Training establishment / Level / Hours of tuition / Qualifications /
CURRENT EMPLOYMENT
Post title:
Date commenced:
Organisation name, address & telephone number:
Details of post:
QUESTIONS
Please continue on a separate sheet if you need more space for any of these responses
1.  Please describe any experience you have of using counselling skills.
2.  Please describe your understanding of what counselling skills are
(Min 100 words)
3.  Please discuss your own view of your present strengths and weaknesses in the role of helper.
(Min 100 words)
4.  Please discuss your motivation for applying for this course and what you hope to achieve from the course.
(Min 100 words)
5.  Please discuss your understanding of diversity and difference.
(Min 150 words)
6.  Please write anything else which you would want us to know about you in support of your application. Include information such as personal qualities, life experiences, relevant experiences not referred to elsewhere in the form. If you need more space, please continue on a separate sheet with 6. marked at the top.)
(Min 150 words)
7.  Please include here any health issues, such as depression, asthma, diabetes or epilepsy and any learning difficulties, such as dyslexia or dyspraxia. Please also discuss any personal experiences that may come up for you during training that may cause you any distress. (If you need more space, please continue on a separate sheet with 7. marked at the top. Please note that this information is confidential, and we ask so that we can ensure we are able to support you.)
DECLARATION SIGNATURE
I certify that all the entries are correct and I undertake, if admitted, to observe the regulations of Swarthmore Education Centre.
Signature …………………….……………………………………. Date ………………………….

You are required to submit a reference. The reference should reflect on any experiences and/or qualifications shown in the application form. If you have attended an Introduction to Counselling Skills then your referee could be your tutor from the course you attended. A form for the reference is attached.

Reference

Note to referee: You may continue on a separate sheet if necessary. Please return your reference to the applicant in a sealed envelope to be forwarded with their application.

Name of applicant:
Name of referee:
Post/occupation
How long have you known the applicant:
Relationship to applicant:
Address:
Telephone number:
Fax number:
E-mail

Please comment on the applicant’s personal qualities and general character.

Please comment on the applicant’s reliability, personal integrity and honesty.

Please comment on the applicant’s relationships with others / peers.

Please comment on the applicant’s ability to work in a group / team working.

What do you regard as the applicant’s significant strengths and limitations in relation to studying for a certificate counselling?

Additional information:

Referee’s signature: …………………………………….……………… Date: …………………….....

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