121 - VOLUNTEER STUDENT COUNSELLOR APPLICATION FORM

Name

Date of Birth

Date

Marital Status

If married, previous name(s):

Address

Post Code

Home telephone number

Mobile Number

Email address

example@example.com

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?

YesNo

If yes please give details

Please give details of Counselling training course venue, full course title, level and specification. Awarding body for the course and Affiliation (if applicable).

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.

If you have not been living at your present address for the last five years please give details of previous addresses for last five years, with dates. (Required for police check)

How many personal therapy hours have you had?

Any other work or personal information which you feel would be useful

As an organisation we are affiliated to the BACP (British Association for Counselling and Psychotherapy) and therefore work within the BACP ethical framework. Are you a BACP member or willing to become a student member?

YesNo

Have you previously applied to become a volunteer with the One to One Project?

If yes, when was this?

Enhanced DBS Certificate Number (if applicable)

I agree to contribute £38 towards the cost of Enhanced DBS Certificate

YesNo

Full Name and Address of three referees who we will contact to support your application: (One must be from your G.P. to state there is not a mental health/medical reason why you should not do this work, one must be from your tutor and the third a character reference

Tutor's Name

Tutor's Address:

Tutor's Post code

GP Name:

GP Address:

GP Post code

Character Reference Name

Character Reference Address

Character Reference Post Code

Signature

Date