BUCKINGHAMSHIRE MIND

COUNSELLING SERVICES

NAME

ADDRESSHOME TEL:

MOBILE TEL:

______EMAIL: ______

Preferred Location: Aylesbury High Wycombe (please circle preference)

______

Please detail previous work or experience, whether paid or not. Starting with the most recent. We are also interested in your life experience which you consider relevant to the voluntary work you wish to pursue. Continue on a separate sheet if necessary.

Employer/Other Position Dates Reason for Leaving

Please include here relevant details of any training courses that you have attended or are attending

(Please include relevant professional qualifications)

COURSE TITLETRAINING AGENCYDATESQUALIFICATIONS (if any)

Personal Statement.

Please state here why you wish to undertake an honorary counselling placement with Buckinghamshire Mind and set out your own assessment of your personal strengths and attributes which you believe will assist you as a practitioner. (Please use continuation sheet if required):

BUCKINGHAMSHIRE MIND

COUNSELLING SERVICES

Personal Therapy

We believe that experience as a client in personal counselling/therapy is essential in developing individual competence as a practitioner. The reasons for this are (a) to have first hand experience and understanding of what it means to be a client and (b) to ensure as much as possible that the practitioner does not bring his/her own limitations and difficulties to the therapeutic relationship.For these reasons we require that you have had or are currently undertaking personal therapy

Time Commitment

Which day(s) / times would you be available?

Please indicate by ticking the appropriate box.

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday
Morning
Lunchtime
Afternoon
Evening

REHABILITATION OF OFFENDERS ACT 1974

Due to the nature of the work for which you are applying the post is ‘exempt’ from the Rehabilitation of Offenders Act 1974. Applicants are therefore not entitled to withhold information about convictions (which for other purposes are ‘spent’ under the provisions of the act).

Please sign below and state whether or not any court has at any time found you guilty of an offence. If yes, please give details.

If no, please state ‘No Convictions’ ......

Signed: ...... Date ......

Any other comments:

NAME & ADDRESS OF TWO PERSONS WILLING TO SUPPLY REFERENCES

(ONE OF SHOULD BE YOUR PRESENT/MOST RECENT EMPLOYER, IF RELEVANT).

  1. Name ………………………………………………………………………………………

Address……………………………………………………………………………………

……………………………………………………………………………………………..

Contact number………………………………………………………………………….

E-Mail……………………………………………………………………………………..

  1. Name …………………………………………………………………………………….

Address ………………………………………………………………………………….

…………………………………………………………………………………………….

Contact number………………………………………………………………………….

E-Mail …………………………………………………………………………………….

WE MAY CONTACT YOUR TRAINING ESTABLISHMENT – PLEASE GIVE DETAILS AND INCLUDE NAME OF YOUR TUTOR:

……………………………………………………………………………………………

……………………………………………………………………………………………

……………………………………………………………………………………………

You will be required to undergo an Enhanced DBS check if accepted for an Honorary Placement. (Please enclose a copy of any existing DBS Disclosure that you have).

I confirm that all the information I have given throughout the application is true and correct:

Signed ……………………………………………………. Date …………………………….

Please return completed application form to FAO Beverley Taylor

or to

Ashton House,

14 Granville Street,

Aylesbury,

HP20 2JR

(Please use this additional sheet if you would like to add anything else in support of your application)