Counselling Survivors of Childhood Sexual Abuse and Sexual Violence2017

Application Form

Nexus Level 5 Diploma in

Counselling Survivors of Childhood Sexual Abuse and Sexual Violence2017

FOR OFFICE USE ONLY

Reference number
TR2017- / Title of Position
Candidate Nexus Level 5 Diploma / Date

Personal Details

Surname (Block Letters) / Title
First Name (s) / Previous Surnames
Address / Daytime Telephone Number
Mobile Number
Email Address

Employment History

Beginning with your current or most recent position, please provide details of your employment in the field of counselling, either paid or voluntary. Continue on a separate sheet if necessary.

Name of Organisation / Title of Position / Start Date
Reason for Leaving / Finish Date
Full-time  Part-time  / Paid  Voluntary 
Principle Duties
Name of Organisation / Title of Position / Start Date
Reason for Leaving / Finish Date
Full-time  Part-time  / Paid  Voluntary 
Principle Duties

Demonstrating your Relevant Experience and Qualifications

In the following section outline how you meet the eligibility criteria for this course. This information will be used by the panel when shortlisting. You must clearly demonstrate how you meet each criterion and give relevant examples. The shortlisting panel will not make assumptions as to your knowledge or experience.

Candidates must have achieved the CPCAB Level 4 Diploma in Therapeutic Counselling (TC-L4) or its RPL equivalent (minimum 450 Guided Learning Hours), in addition to appropriate pre-TC-L4 (or equivalent) training.
Please provide details in Appendix A of this form.
Be a member of BACP or IACP and be accredited or actively working towards accreditation.
Please provide the name of the professional body you are a member of, your level of membership and your enrolment Number.
Professional Body:
Membership Level:
Enrolment Number:
Have you achieved accreditation or are you working towards it? Yes  No 
If working towards accreditation, when is your anticipated date of submission?
______
Has a complaint ever been upheld against you, following a formal complaints procedure in your capacity as a counsellor? Yes  No 
If YES, please specify:
Have you been refused membership of, or had your membership cancelled by a professional organization in the counselling field? Yes  No 
If YES, please specify:
Candidates must have a minimum of 100 hours of supervised clinical practice at the time of application.
Please provide details in Appendix B of this form.
Candidates must have undertaken a minimum of 10 hours of personal therapy at time of application.
Please provide details in Appendix C of this form.
Candidates must be a minimum of 19 years of age at the time of application.
Explain and demonstrate how you meet the criterion
Candidates must be able to demonstrate by way of written submission their experience or interest in working with survivors of childhood sexual abuse or sexual violence in a therapeutic or support role.
Explain and demonstrate how you meet the criterion (Maximum of 300 words; continue on a separate sheet if necessary)
Candidates must be able to use online learning resources and communication systems.
Explain and demonstrate how you meet the criterion

Disability Discrimination

The Disability Discrimination Act protects people with disabilities from unlawful discrimination. We actively encourage applications from people with disabilities.
Do you have a disability which is relevant to your application: Yes  No 
If yes please give details:
We will try to provide access, equipment or other practical support to ensure that people with disabilities can compete on equal terms with non-disabled people.
Do we need to make any special arrangements in order for you to attend the interview?
Yes  No 
If yes please give details:

Medical History

Have you ever received psychiatric treatment or been treated for drug and/or alcohol problems?
Yes  No 
If yes please supply details:
This information will be held in confidence and may not necessarily deter selection.

References

Please give the names of two referees, (neither of whom is related to you) both of whom should be familiar with your work as a counsellor. One of the two must be a supervisor who has provided supervision to you over the course of the past year. (Referees will not be contacted unless you are offered a place on the course )
Name / Name
Occupation / Occupation
Address / Address
Post Code / Post Code
Telephone Number / Telephone Number
Email / Email

Interview Arrangements

Candidates will be required to attend interview to assess their suitability for the training and clinical placement element of the course.
Interviews for places on the course will be arranged in the order that applications are received. Places on the course are limited to 15 and applications will close when enough candidates are selected.
We will do our best to accommodate candidate availability, but if you are unable to attend an interview when offered the slot will be given to the next available candidate.

Advertising

Please state how you became aware of this course.

Protection of Children and Vulnerable Adults

Are you aware of any police enquiries undertaken following allegations made against you, which may have a bearing on your suitability for this post? Yes  No 
If yes please give details:

ACCESS NI (Criminal Conviction Checks for Regulated Activity Posts)

Successful candidates will be subject to an Enhanced Access NI check prior to confirmation of a clinical placement at Nexus. The Access NI Code of Practice is available to applicants on request.

Before selecting anyone to a position which has access to clients it is Nexus NI policy to ask for a Protection of Vulnerable Adults Access NI Service check to be carried out by the Department of Health, Social Services and Public Safety (DHSSPS). The check is to make sure that people who might be a risk to vulnerable adults are not appointed. As this course involves a placement with Nexus clients this is required.
The check will tell us if you have a criminal record, or if your name is included in the DHSSPS Disqualification from Working with Vulnerable Adults List. Any information, which we receive, will be treated confidentially, and we will discuss any issues with you before we make a final decision. After that decision is made the information will be destroyed.
We will only ask for the check if your application for the course is successful. However, you must tell us now (by completing form TR13 at the end of this form) if you have ever been convicted of a criminal offence, or cautioned by the police, or bound over. You must include all offences, even minor matters such as motoring offences, and ‘spent’ convictions, that is, things which happened a long time ago. If you leave anything out it may affect your application.
Please give your written consent to the Access NI Enhanced Security check.
Please note that if you do not consent we will not accept your application.
I consent to an AccessNIcheck being carried out to assess my suitability for a clinical placement on this course.
Yes No 
I understand that an Access NI check must be carried out before any clinical placement on the course can be confirmed. This has been explained to me and I am aware that spent convictions may be disclosed. I declare that the information I have given is accurate and I consent to the check being made.
Signature: ______Date: ______
Print Name: ______National Insurance No: ______

Availability for Clinical Placement

Please indicate ALL the times and days you would be available to see clients if you are successful in being offered a place on the course and a clinical placement at Nexus.
Monday: Morning  Afternoon  Evening 
Tuesday: Morning  Afternoon  Evening 
Wednesday: Morning  Afternoon  Evening 
Thursday: Morning  Afternoon  Evening 
Friday: Morning  Afternoon  Evening 

Personal Declaration

I declare that to the best of my knowledge the information given above is honest and accurate. I understand that any wilful misstatement or omission renders me liable to disqualification or, if accepted onto the course, removal.

I understand that any offer of a place on the course is subject to receipt of satisfactory references, the verification of qualifications or accreditations required for the course (as per the criteria) and relevant security check.

I hereby give consent for the information on this form to be collected, stored and processed in accordance with the provisions of the Data Protection Act 1998

Signature ______

Date ______

Monitoring Forms

Please complete the Equal Opportunities Monitoring Form (TR01) included at the end of this form and return it with your application.

If sending in your application by post, please place this form in a separate sealed envelope marked: Monitoring Officer.

Criminal Convictions Disclosure (Regulated Activity Posts)

Please complete the Criminal Convictions Disclosure Form (TR13) included at the end of this form and return it with your application.

If sending in your application by post, please place this form in a separate sealed envelope marked: Confidential.

These forms will not be disclosed to anyone involved in the interview process.

Appendices

Please complete the information in the appendices that follow to demonstrate how you meet the eligibility criteria for entrance on this course. Please provide evidence to verify that any information you provide is true and correct.

Applications will remain open until the course is full.If a high number of applications are received then additional candidates may be placed on a reserve list for the next course, or be offered a place on the current course if places become available.

Please return this completed application form to:

L5 Diploma

c/o Training

Nexus NI

119 University Street,

Belfast,

BT7 1HP

Or by email to:

TR16 – Candidate Application Form - Aug 2016

APPENDIX A: COUNSELLING QUALIFICATIONS

Please use this form to demonstrate how you meet the criteria for entrance onto the course. Please continue on a separate sheet if necessary. You will be asked to bring along original certificates or diplomas to verify qualifications if invited to interview.

DATES
FROM AND TO / DURATION OF COURSE/
NO OF HOURS / TITLE OF COURSE
AND ACCREDITING BODY / COLLEGE OR UNIVERISTY / QUALIFICATION GAINED

COUNSELLING/PSYCHOTHERAPY TRAINING (PAST & PRESENT)

(Please detail all training received beginning with the most recent)

MONTH
YEAR / NO OF HOURS / WITH WHOM / ACCREDITED BY / DETAIL OF MODULE/CONTENT / QUALIFICATION ATTAINED

APPENDIX B: COUNSELLING PRACTICE

Please use this template to provide evidence that you meet the course requirements of having completed a minimum of 100 hours of supervised client work at the time of application. Show the actual hours you worked face to face with clients excluding – assessment interviews, cancelled or missed appointments, sessions not attended by the client, training or supervision.

Your supervised practice must be with a qualified supervisor and the name and qualifications of the supervisor must be included.

You must also provide evidence to confirm the information provided, i.e. a signature from your supervisor. Please continue on another sheet if necessary.

MONTH
YEAR / NO OF
HOURS / NATURE AND SETTING OF WORK / TYPE:
GROUP/INDIVIDUAL/
OTHER / SUPERVISOR DETAILS
(NAME/ADDRESS/
QUALIFICATIONS) / SUPERVISOR’S SIGNATURE

APPENDIX C: PERSONAL THERAPY & OTHER RELATED INFORMATION

Please use this template to demonstrate how you meet the course requirement of having completed a minimum of 10 hours of Personal Therapy at the time of application.

You must also provide evidence to confirm the information provided, i.e. a signature from your therapist, or if this is not possible, the contact details of your therapist to confirm the information provided.

MONTH
YEAR / NO OF
HOURS / CONTENT / WITH WHOM / ACCREDITED BY / THERAPIST SIGNATURE OR
CONTACT DETAILS
COMMENTS:

TR16 – Candidate Application Form - Aug 2016

REF:

TR01-Equal Opportunities Monitoring Form

Statutory Monitoring:

Since 1990, under Fair Employment Legislation, specified public authorities and registered employers have a legal duty to monitor the community composition and sex composition of their workforces.

Community Background

Regardless of whether we practice religion, most of us in Northern Ireland are seen as either Catholic or Protestant. Please indicate the community to which you belong or are perceived to belong to, by ticking below:

I am a member of the Protestant Community
I am a member of the Roman Catholic Community
I am a member of neither the Protestant or the
Roman Catholic Community

Gender

Male
Female

Marital Status

Married
Single
In a civil partnership
Other

Age Band

16-21
22-30 / 51-60
31-40 / 61-65
41-50 / 65+

Disability:

Under the Disability Discrimination Act 1995 a person is considered to have a disability if he/she has a physical or mental impairment which has a substantial and long-term adverse effect on his/her ability to carry out normal day to day activities. Please note that it is the effect of the impairment, without treatment, which determines if an individual meets this definition of disability.

Do you consider that you meet this definition of disability?

YesNo

Ethnic Group

Please indicate which Ethnic Group you belong to:

BangladeshiPakistani Black AfricanWhite

Black CaribbeanIrish TravelerChineseIndian

Please Note:

It is not compulsory for you to answer the above questions. However I would stress that it is a criminal offence under the legislation for a person to “give false information in connection with the preparation of a monitoring return”.

Any queries you have may be raised with:Monitoring Officer

028 9032 6803

Please return this information by email or enclose it in a separate envelope along with your application if submitting your application in hard copy.

Thank you for your assistance.

TR13 - DISCLOSURE OF CRIMINAL CONVICTIONS

APPLICANT : ______

ROLE:Candidate Nexus CPCAB Level 5 Diploma

Please read this information carefully.

Statement of non–discrimination

Nexus NI is committed to equality of opportunity for all applicants including those with criminal convictions. Information about criminal convictions is requested to assist the selection process and will be taken into account only when the conviction is considered relevant to the role. Any disclosure will be seen in the context of the role description, the nature of the offence and the responsibility for the care of existing clients/volunteers and employees.

Advice to Applicants

You have applied for a role which is a ‘Regulated Activity Position’ as defined by the ‘Safeguarding Vulnerable Groups (NI) Order 2007’ and also falls within the definition of an“excepted” Order (NI) 1979: therefore ALL convictions including SPENT convictions MUST be disclosed. Having a conviction will not necessarily debar your application from being considered. This information WILL be verified through an appropriate Access NI Enhanced Disclosure check. If you have received a formal caution or are currently facing prosecution for a criminal offence you should also bring this to our attention given the “excepted” nature of the role.

Please complete this disclosure form as accurately as possible.If returning your course application by post, please return this form in a separate sealed envelope marked, “Confidential” and return it with your application form. A separate arrangement will be made with you if clarification is required to discuss any issues around your disclosure before a final decision is reached about offering you a place on the course.

Question

Are you currently subject to inclusion on:

A) The Children’s Barred List Yes  No 

B) The Vulnerable Adult’s Barred List Yes  No 

If you have answered YES to either of the above questions please provide details below.

Do you have any CONVICTIONS, CAUTIONS OR CASES PENDING? If not please state NONE.

DATE OF CONVICTION / OFFENCE / SENTENCE

Please provide any other information you feel may be of relevance such as:

The circumstances of the offence
A comment on the sentence received
Any relevant developments in your situation since then
Whether or not you feel the conviction has relevance to this role

Please continue on a separate sheet if necessary.

As per Access NI Code of Practice Nexus NI has a policy on the recruitment of Ex-offenders (HRP42) which is available on request.

I declare that any answers are complete and correct to the best of my knowledge. I give my consent for an Access NI Enhanced check to take place and for this information to be shared as part of Nexus NI’s risk assessment process.

SIGNED: ______DATE: ______

TR16 – Candidate Application Form - Aug 2016