Counsellor Placement Application

The Eve Project Counselling Service

You will be required to upload proof of your ‘Readiness to Practice’ and official Counselling Membership in this application.
The Eve Project is committed to providing the best possible counselling service and therapeutic intervention to the users of our services.

Please email your form to: counselling@evetherapy.com
Personal Details
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Date of Birth*

DayMonthYear
Date
Languages spoken other than English
Gender
How would you describe your gender?*
How would you describe your ethnicity?
How would you describe your ethnicity?*
Are you fluent in any other language(s) other than English?

YesNo
If you answered 'yes', please tell us below what other languages you are fluent in?*
DBS
1. Do you have a current DBS (Disclosure and Baring Service)*

YesNo
If yes, when was it issued?

DayMonthYear
Date
Please note all placement are required to undergo criminal record checks as provided by the Disclosure and Barring Service (DBS). This record check will include details of cautions, reprimands or
final warnings, as well as convictions. A criminal record will not affect your chances of volunteering unless we decide it makes you unsuitable.

The nature of the offence, how long ago and what age
you were when it was committed, patterns of offending and any other relevant factors will be considered. Any information will be kept in strict confidence and will be stored securely. If these
checks reveal evidence we believe makes you unsuitable to volunteer with us either at the start of the process or any time later, we will not be able to start/continue the volunteering relationship. By signing this application you are giving your consent to these checks being carried out at any time
during your volunteering with The Eve project.
1. Have you ever been convicted of a criminal offence? Please answer:*

YesNo
If your answer is YES, please give details of date(s) of offence(s) and sentence(s) passed.
Course Details

The following questions are designed to provide a succinct summary of your counselling experience and qualifications. There is an opportunity for you to elaborate below.

Counselling Qualification/Training*

	Name of College/University?	Name of Course	Dates@ From - To	Areas covered
1.
2.
3.
4.
5.
6.
7.

Placement Availability & Commitment (minimum commitment of three hours per week):*

	Monday	Tuesday	Wednesday	Thursday	Friday
9am-12pm
12pm-3pm
3pm-6pm
6pm-9pm

Practical Counselling Experience*

	No. of Hours	Counselling Orientation
Face to Face
Telephone.
Online .
Group
Personal Therapy

Theoretical OrientationDescribe the theoretical base of your training so far (maximum - 300 words):*
Personal Therapy: Tell us about your experience (maximum - 300 words):*
Counselling Experience

.
Counselling ExperiencePlease give details of any practical counselling experience: (maximum - 300 words):*
Additional Information:Please give details of any other relevant experience/voluntary work: (maximum - 300 words):*
The Role of a Counsellor

.
Describe how you perceive the role of the counsellor and what particular skills you have to carry out this role. (maximum 300 words):*
What life experience(s), if any, may have an influence on your role as a counsellor? (maximum 300 words):*
Employment Record

.

Starting with your most recent appointment*

	Name of Employer	Job Description	Start Date	End Date
1.
2.
3.
4.
5.
6.
7.

Referees

Please give full contact details for two referees, one of whom must be from your tutor or equivalent from your current ounselling course:
Referee 1:
Name.*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Relationship:*
How long have you known this referee?*
Referee 2:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Relationship:*
How long have you known this referee?*
Declaration

I certify that the information given above is a true and accurate record and understand that should I provide false/inaccurate information, my application or placement will be ended without notice.
Signature*

Clear
Date*

DayMonthYear
Date
Thank you for taking the time to complete this application.
Should be Empty:

The Eve Project Counselling Service

Personal Details

Gender

How would you describe your ethnicity?

DBS

Course Details

Counselling Experience

The Role of a Counsellor

Employment Record

Referees

Declaration