Placement Application Form

To apply for a placement please fill in the form below. If there are any parts that are not relevant please enter N/A.

Name:
Email Address:
Marital Status
Ethnic Origin
Date of Birth
Required Placement
Personal Therapy required by CT as part of placement

Supervision

It is a requirement for all Trainee and Qualified Counsellors that you attend a minimum of 1.5 hours of monthly Clinical Supervision
Please select if you have your own Clinical Supervisor and provide details below, or select that you wish to take up Clinical Supervision with Counsellors Together.
Required Supervision
Current Supervisor Name
Telephone number
Email address
No. of Supervised Hours Accrued
Date of last Supervision

Personal Details

Home Address
Postcode
Phone No.
Mobile Phone
N.I. Number

Person to Notify in Case of Emergency

Name
Address
Postcode
Phone No

Training & Qualifications

QualificationsEducation and Professional Qualifications: (please include Subject, Place of study, Result and Year obtained).
Training Courses Attended
Membership of Professional bodies: (please include Name and Registration number and Expiry date).

Your Professional Liability Insurance Details

Insurance Company
Policy No.
Expiry Date
DBS

In order to volunteer with our organisation, we will need to complete a DBS check for you before you can start your role, please tick to state that you agree to this and by agreeing, you agree to pay the fee of £12.00 in order to process your DBS

In order to progress your DBS application after interview stage, once you have been accepted, we ask that you provide the following information at application stage.
Place of Birth
County of Birth
Country of Birth
Surname at Birth
Nationality at Birth
Name Changes Since BirthPlease list any name changes since birth, with dates changed from and to (DD/MM/YY), in sequence and significance i.e. Change of surname, middle name, or first name.
Last 5 years of AddressesPlease list the last 5 years of address you have lived at, with the date when you moved in and out (DD/MM/YY).
At interview stage you will be asked to bring in relevant original ID and documents for your DBS application to be processed. You can view the relevant ID and documents that are required, on the government website. ID must be in date and originals and documents must be dated within the last 3 months and originals.

Employment History

EmployerPresent employer/most recent employer
Address
Postcode
Job Title
DutiesBrief description of your duties and responsibilities
Reason for leaving (if applicable)
Date Employed From
Date Employed To
Please tell us about other jobs you have done and about the skills you used, or learned in these roles.

Other Information

Please provide any further supporting information and tell us about your interest in this role.
Have you ever been convicted of a criminal offence?
(Declaration subject to the Rehabilitation of Offenders Act 1974)
If you have a disability please tell us about any adjustments we may need to make to assist you at interview
What particular support requirements do you have to enable you to work with us
Interview AvailabilityPlease tell us if there are any dates when you will not be available for interview
How did you hear about our organisation?



It is a requirement of Counsellors Together that we obtain two current and relevant references, before you are accepted for a placement ? Please provide details of how best to make contact.

Reference 1) Counselling Tutor (most recent)
Name
Position/Title
Relationship
How long
Email
Phone
Mobile

Reference 2) Employment reference (most recent)
Name
Position/Title
Relationship
How long
Email
Phone
Mobile
Where did you hear about our service

Agreement and Submission

By selecting 'I Agree' below I declare that the above information is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting this application or be grounds for dismissal. Where applicable, I consent that the organisation can seek clarification regarding professional qualifications and registration details.

Human Verification

To prove you are a real person please select all the blue shaded boxes by clicking on them below.





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