FOR OFFICE USE ONLY

Date form received:

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REF 1

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REF 2

Received after deadline:

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Interview date:

Other notes:

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Interview outcome:

CERTIFICATE IN COUNSELLING SKILLS - APPLICATION FORM(electronic version)

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 (if possible) and check your final version before e-mailing your application to us at:

PLEASE TICK ONECOURSE ONLY – Weds or Thurs
PC300 Wednesday afternoon
September 2014–June 2015
Helene Baker & Maya Gagni / PC302 Thursday evening
September 2014–June 2015
Puja Hawkins & Sharon Zierler
Please indicate interview dates you are able to attend with ‘Y’ and those you cannot with ‘N’:
While we cannot guarantee it, we will try our best to match your availability
For PC300 ONLY– Weds 18 June Weds 25 June Weds 2 July
For PC302 ONLY – Thurs 19 June Friday 20 June Thurs 26 June Fri 27 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.
Please note that it is your responsibility to contact your referees (unless your referee is your L1 tutor at City Lit). For more information see the application guidelines and reference pack.
Referee 1 / Referee 2
Tutor name: / Name:
Place of study: / Relationship:
Course code
(City Lit L1 students): / Full address:
Have you completed a 30-hour Level 1 counselling course (i.e. Counselling: an introduction) or equivalent
within the last 3 years?
Are you currently attending a 30-hour Level 1 counselling course?
Please note that you need to have answered yes to one of the above in order to apply for the Level 3 Certificate.For more information see the application guidelines.
You will need to provide an attendance certificate for Counselling intro/level 1 - how will you provide this?
Attached to with application In the post Can bring to interview
Please do not provide the original
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)

COUNSELLING COURSES ATTENDED

Date

/

College/provider

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Course name and tutor

/

Number of hours of attendance. Please attach an attendance certificate.

EMPLOYMENT

Current employment, paid or unpaid.

(Up to 50 words)

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

EDUCATION/TRAINING HISTORY

Date
From / To / Name of School, College
Or University / Course or subjects taken / Qualification (if any)

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

Please tell us what has led you to wanting to do this course at this particular time in your life.
(Up to 300 words)
Please tell us what you hope to gain from this course.
(Up to 150 words)
Please tell us what you hope to offer this course.
(Up to 150 words)
Being in a large group can be challenging. What are your thoughts and feelings about the challenges of learning and getting your needs met in a group of 22 people?
(Up to 150 words)
You would be required to write a weekly journal, and five assignments of between 1500 and 2000 words. Would this present any difficulties for you? (We need to know so that we can begin to assess the support you might need.)
(Up to 150 words)
What are your thoughts about the financial and time commitments of the course in relation to your current life?
(Up to 150 words)
What are your thoughts about any other possible difficulties this course may present you with? How would you handle these?
(Up to 150 words)
Please use this space to tell us about any history of mental health problems or addictions, recent loss and anything else you would like us to know.
(Up to 150 words)

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 it is from your own e-mail address.