121 - One to One Volunteer Counsellor Application Form

One to One Project Counselling Mentoring Group Work
VOLUNTEER COUNSELLOR APPLICATION FORM
Name*
Date

DayMonthYear
Date
Marital Status
If married, previous name
Home Telephone No:
Mobile No:
Email Address:*
How long have you lived in this area?
Place of Birth
Number of Children
Age(s)
Please list your hobbies/interests
Are you, or have you ever been, an assistant in social work or other voluntary organisations?
Please give details of any training or other experience which you feel will be helpful in this work
What do you imagine you would be able to offer a client?
What times would you be available for volunteer work? Please state day(s)/time(s):
Have you ever been convicted of a criminal offence? If so please give details. We are required to submit a police check with the Disclosures and Barring Service on behalf of all volunteers.

YesNo
If so please give details. We are required to submit a police check with the Disclosures and Barring Service on behalf of all volunteers.
If you have not been living at your present address for the last five years please give details of previous addresses for the last five years, with dates. (Required for the police check).
How many personal therapy hours have you received in the last 12 months?
Any other work or personal information which you feel would be useful
Have you previously applied to become a Volunteer with the One to One Project? Yes/No

YesNo
If yes, when was this?
Full Name and Address of two referees who we will contact to support your application: (One must be from your G.P. to state that there is not a mental health/medical reason why you should not do this work and the other must be a character reference)
GP
GP Address:
GP Postcode
Character Reference (Name)
Address:
Post code
Signature

Clear
Date

DayMonthYear
Date
Should be Empty:

One to One Project Counselling Mentoring Group Work

VOLUNTEER COUNSELLOR APPLICATION FORM