Certificate in Counselling Skills: Application Form

1. Your Contact Details

FULL NAME / TITLE
ADDRESS
POSTCODE / DATE OF BIRTH
PHONE / HOME / MOBILE
EMAIL

2. About You

1 / What is your experience of using counselling skills in a helping relationship?
2 / Why are you interested in developing your counselling skills?
3 / What qualities would you bring to this course?
4 / This course can be emotionally demanding. What kind of support do you have in place to manage this?

3. Current or Most Recent Employment

EMPLOYER NAME / FROM / UNTIL / DESCRIBE THE NATURE OF YOUR WORK

4. Qualifications

DATE / QUALIFICATION / AWARDING BODY

5. Payment

Full Course / £1000

(If we have capacity we may be able to consider students who wish to resume their studies after successfully completing one or more modules elsewhere. Please apply for costs.)

6. Payment Details

How do you intend to fund your studies if your application is successful? (Tick box)

Self-funding
Paid by employer
Other (please specify):

If your application is successful a non-refundable deposit of £250 will be required to secure your place. The outstanding balance will be requested 4 weeks prior to the start of the course/module.

Please confirm your preferred payment method below. (Tick box):

Cheque
Internet Banking

7. Data Protection & Information Sharing

The information you have given is confidential. The data will be used in the selection process and if your application is successful it will form the basis of your personal file. It may be held on computer and manual records and be shared with COSCA, the course awarding body, who maintain a register of course participants. If you are not successful the data will be kept for 6 months and then destroyed.

FDAMH’s registration number with the Information Commissioner’s Office is Z8152509. If you would like more information about data protection contact the Information Commissioner’s Office: 0131 244 9001 or visit their website at: www.ico.gov.uk

8. Declaration

I certify that all of the information I have given on this form is correct and complete. I confirm that I have read and understood the accompanying document “Information for Applicants”.

Signature of Applicant………………………………………………………..Date……………………

(If you return this form electronically you may leave the signature field blank and you will be asked to sign your form in person if your application is successful)

Please tell us how you heard about the course:

……………………………………………………………………………………………………………

What Happens Next?

Send this form by post to FDAMH, The Victoria Centre, 173 Victoria Road, Falkirk, FK2 7AU or by e-mail to . Your application will be considered by the trainer and you will be notified of the outcome within 3 weeks of receipt.