FOR OFFICE USE ONLY

Date form received:

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REF 1

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REF 2

Date of interview:

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Recommended action:

Interview outcome:

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Student’s decision:

PC303Diploma in Therapeutic Counselling

Thursdays 10:00 – 17:30 / Sept 2015 – July 2017

APPLICATION FORM
Please read the course leaflet and application guidelines before completing this form.
We recommend you save the form to your PC or storage device before starting work on it. Save, print and check your final version before e-mailing your application to us at:
Please indicate interview dates you are able to attend with ‘Y’ and those you cannot with ‘N’:
Saturday 13 June Saturday 20 June Wednesday 24 June

PERSONAL DETAILS

First name: / Surname:
Title (Mr,Ms etc): / Date of birth:
CONTACT DETAILS
ADDRESS line 1: / ADDRESS line 2:
TOWN: / POSTCODE:
Mobile phone: / Tel (home):
Tel (work): / e-mail:

REFEREES

Please give the name of two referees. The first one should be a tutor of a counselling course you have attended. The second one should be someone who knows you well, preferably in a work context and not a personal friend or counsellor.
Name: / Name:
Relationship: / Relationship:
Full address: / Full address:
Do you have any difficulties or disabilities which you consider we need to know about in order to help you at interview and later with your learning? (We have a wide range of support for students and we are committed to making our courses accessible to potential students)
(Up to 50 words)
How would you describe yourself in terms of your origins and background?
(Up to 50 words)

EDUCATION & PROFESSIONAL TRAINING

(Please note, COUNSELLING TRAINING TO BE DETAILED IN A LATER SECTION)

From / To /

Name & address of School, College or University

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Course or subjects taken

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Qualification and grade (if any)

WORK HISTORY (paid and voluntary)please include any roles within the helping professions
From / To / Place of work / Position held and main responsibilities

COUNSELLING SKILLS TRAINING

Please list all counselling skills training courses with the most recent first.

PLEASE NOTE: you will be asked to bring a copy of all certificates gained whether these are attendance certificates or externally validated certificates to INTERVIEW

Date
From / To / Course title (hours in brackets) / College / University or
Training Establishment / Award or qualification / Main model of counselling

Use the sections below as an opportunity to help you decide if this is the right course for you.

  1. Please reflect on your reasons for wanting to embark on this course at this time in your life.
(Up to 300 words)
  1. Please write about your strengths and weaknesses in the role of the helper
(Up to 150 words)
  1. This course is committed to anti-oppressive practice: please describe your understanding of this in your life, work and training.
(Up to 150 words)
  1. Please describe the ways in which the Person-Centred approach, as you currently understand it, relates to your own personality and experience. Comment on both the ‘conflict’ as well as the ‘fit’.
(Up to 150 words)
  1. What attracts you to this particular course with its emphasis on group participation, self and peer assessment, and self-directed learning?
(Up to 150 words)
  1. Please describe an experience which has contributed to your own self-awareness and tell us about your commitment to personal development.
(Up to 150 words)
  1. What makes you confident that you can handle the theoretical parts of this course, including thereading and written assignments, especially when you are under pressure?
(Up to 150 words)
  1. What makes you confident you can handle the emotional demands of the course, especially when you are under pressure?
(Up to 150 words)
  1. Please tell us what you intend to offer this course?
(Up to 150 words)
  1. Please tell us what you hope to gain from this course?
(Up to 150 words)
  1. How do you intend to meet the financial and time commitments of the course?
(Up to 150 words)
  1. Please use this space to tell us about any history of mental health problems, addictions or other health issues. (Having a history does not necessarily mean exclusion from the course. However, failure to disclose information may do so.)
(Up to 150 words)
  1. Please tell us about any major life events in the last five years (eg. Marriage, bereavements, adoption, child birth, migration)
(Up to 150 words)
  1. Please tell us about any criminal or civil convictions, whether spent or unspent. Disclosure of information does not automatically exclude you from being accepted on the course. However, failure to disclose information about convictions may result in you being asked to leave the course. Placements will require a CRB check.
(Up to 150 words)
  1. Please write here anything else you would like us to know about you.
(Up to 150 words)

DATA PROTECTION STATEMENT:

All data are collected for selection purposes and monitoring of applicants. Information you provide on this form will be used for these purposes only and will be processed in compliance with the Data Protection Action 1998. Further information about Data Protection is available on request.

APPLICANT'S DECLARATION

I confirm that, to the best of my knowledge, the information given on this form is correct.

Signed: ______Date: ______

If you are sending us this form by e-mail we will accept it without a signature as long as you are sending it from your own e-mail address.