Relate Training Application Form

Relate Training Application Form

An offer of a place will be made upon receipt of all documents, placement confirmation and successful screening by the Training Department.
Whilst a Centre may offer a placement, the Training Department will determine the appropriate level of entry for a student.
Entry criteria can be found on the website:
Please complete the form, ensuring that all information is complete and accurate. All information will be held securely and in compliance with the Data Protection Act (1998) and will be used by Relate for registering students and practitioners and for internal research purposes. It will only be shared with these people/institutions:

• Relate Centres

• Relate Scheme Managers

• Relate National

• Professional Standards Authority for Health and Social Care

• Senior Practice Consultants

• CPCAB/COSRT or relevant accrediting bodies

/

• If you work for a Relate Centre your information will be shared with your Centre Manager
• If you are a Relate Licensed Counsellor (RLC) your information will be shared with your Scheme Manager
• Information may be shared with Relate Nationalfor administrative, workforce development and research purposes
• For initial registration of practitioners if Relate applies for accreditation under the accredited Voluntary Registers scheme
• If it is identified, you require additional professional development support

• For student registration

I agree to Relate Limited holding the information supplied in these application forms and to sharing this information with the above stake holders if necessary
Please print full name
Date
Signature
Personal details
Title First name(s)
Last name (including previous last names)
Home address / Postcode
Email
Daytimephone number / Mobile
Gender
Male / Female / Other / Prefer not to say
Date of birth
Ethnicity
Asian/ Asian British Indian
Asian/Asian British Pakistani
Asian/Asian British Bangladeshi
Asian background Other / Black/Black British Caribbean
Black/Black British African
Black background Other
Chinese / White British
White Irish
White background Other
Languages spoken including British Sign Language
Programme applied for(please circle or highlight)
Relate CPCAB Level 4 Introduction to Relationship Counselling
Relate CPCAB Level 5 Diploma in Relationship Counselling
Relate Certificate in Relational Training
Relate CPCAB Level 6 Diploma in Supervisory Practice
Relate COSRT (approval pending)Professional Certificate in Psycho-Sexual Therapy
Relate Certificate Counselling Young People (11-18 years)
Relate Certificate Family Counselling
Relate Digital Counselling
Venue:
Start date:
Qualifications
Include all counselling/therapeutic qualifications in this section. (A CV will not be accepted). Please send in photocopies of your certificates with this form.
Awarding body
(e.g. University) / Accrediting Body
(e.g. BACP; COSRT: IFT) / Name of programme or title of qualification / Type or level / Date of completion / Grade
Professional Membership
Individual Professional Body Membership (i.e. BACP/UKCP/COSRT/AFT)
Professional Body Membership number
Level of Professional Body Membership
Date of last renewal of membership
Proposed clinical placement
Please indicate where you are applying for a placement:
Organisation name
Address
Telephone number
Current employment
Name of employer / Nature of job / From / To / Full/Part time
References
Please supply the names and addresses of two people willing to give a reference for you.
The referees must not be relatives or in a close personal relationship with you. One should have known you personally for a year or more. One should be someone with whom you have worked in a paid or voluntary capacity. If you have experience practising in a clinical setting, one reference must be from your clinical supervisor.
Please send a reference request form to each referee.
Referee one:
Referee name
Address
Postcode
Email
Phone number
Referee two:
Referee name
Address
Postcode
Email
Phone number
Accessibility & Support
Do you have any difficulties that you feel may affect your ability to study?
This could be a physical disability, a health problem or difficulty with English or maths (e.g. dyslexia)
Yes/No
If yes, please give details
Criminal convictions – all applicants must complete this section
Due to the nature of our programmes, applicants may be required to undergo a Disclosure and Barring Service Check before embarking on our programmes. Please indicate whether you are willing to complete a Disclosure Application: Yes/No
Your placement centre must provide a DBS prior to a course place being confirmedand a placement contract is issued. For registration on the Relate Practitioner Directory we will need details of your DBS
-DBS details provided
Level ______
Issue Number ______
Disclosure date ______
This is the correct level disclosure for the work being undertaken.
No evidence of activity criminal or other wise.
Confirmation from Centre Manager ______
Complaints & Refusals
Are you currently the subject of a complaint to Relate or any other regularity professional body? / Yes / No
Have you ever been the subject of a complaint to Relate or any other regularity professional body where the complaint against you was upheld? / Yes / No
Have you ever been refused recognition, certification or accreditation by any relevant professional body? / Yes / No
Please give details below if you have answered yes to any of the above questions.
Declaration
I confirm that

• the information I have given is true and accurate and that I have not withheld any information relevant to my application.
• I have read, understood and agree to uphold and abide by the British Association for Counselling & Psychotherapy’s Ethical framework for good practice in counselling and psychotherapy, as effective from July 2015 and as amended from time to time, when delivering Relate counselling services to clients, as appropriate to the service being delivered;
• I give permission for information I have provided for this training to be shared with the Practitioner Directory as required.

I understand that

• the information that I have provided on this form and in accompanying papers will be made available to those staff at Relate concerned with student matters.
• any offer of a place as a student on a Relate Training course will be based on the information given in this form and that if the information given is found to be incorrect or incomplete, that any such offer will be withdrawn.

Signed:
Date:

Relate reserves the right to modify and develop its courses (including the location of delivery) and to reschedule a proposed programme if it reasonably considers that to be necessary.

If the programme of study to which the student is enrolled is rescheduled, the student may withdraw from Relate without any liability or fees, or they may transfer to another programme on which a place is available and for which the student is suitably qualified.

Students must supply, and promptly notify any change(s) to data required for official recording and external reporting purposes, which include the processing of such data for any purposes connected to their studies or for health and safety reasons or for any other legitimate reason. Information held regarding students will only be released under the terms of Relate’s registration under the Data Protection Act. These terms are consistent with Relate’s commitment to prevent fraud and the abuse of public funds.

Relate will share the result of your selection with your Placement Centre.

Please send your completed application form together with supporting documents to:

Relate Training Programmes
Relate
Premier House
Carolina Court
Doncaster
DN4 5RA

If you have any questions about the application process please contact the Training Department

CHECK LIST

To ensure that your application is complete and to help assist with a smooth running application process, please ensure that all requirements of the application form are completed by checking the list below.

Missing information and/or documentation may result in your application not being processed or completed in time for your desired course start date.

Check List
-Completed all sections of the application form and provided all requested details/information?
-Signed and dated application form?
-Included photocopies of counselling certificates or qualifications?
-Included evidence of previous counselling skills / clinical hours where applicable?
-Reference forms sent to Referees?
-Included written confirmation of placement?
-DBS detailsprovided

V3– June 2017