VOLUNTEER COUNSELLOR APPLICATION FORM

VOLUNTEER COUNSELLOR APPLICATION FORM

TGCCS do not currently offer remote placements, students are expected toattend our office in person.
PART ONE – YOUR DETAILS
Title
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
How would you prefer we contact you?
How did you hear about Changing Pathways?
Please give details of counselling and other relevant qualifications:
Why do you want to volunteer for TGCCS?
Have you ever experienced (or are you currently livingwith) Mental Health?

YesNo
If yes, how long ago?
Please indicate the times you are available to counsel:

Start?

DayMonthYear
Date
What is your current face to face client hours to date?
What is your current work experience?
Why have you chosen to be a part of Mental Health volunteer atTGCCS?
How well you understand Mental Health and its impact onvictims and carers/families?
Do you have use of your own transport?

YesNo
What type if driving licence do you have?

Please give the details of two referees who may be contacted for
references. If enrolled on an Advanced Certificate, or Counselling Diploma
course, one referee would normally by your course tutor:
Reference 1 details
Title
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tel
Please enter a valid phone number.
Relationship
Reference 2 details
Title
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tel
Please enter a valid phone number.
Relationship

PART THREE - REFERENCES
Where possible, at least one referee should be your current or most recent employer, tutor or from a professional person. Please state the capacity in which they know you. Family members are not acceptable.
Reference Name

First NameLast Name
Reference Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference Tele
Please enter a valid phone number.
Reference Email
example@example.com
Reference Job title
Relationship to you
Reference Name

First NameLast Name
Reference Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference Phone Number
Please enter a valid phone number.
Reference Email
example@example.com
Reference job title
Relationship to you

PART FOUR – CRIMINAL OFFENCES DECLARATION
Please give details of any spent or unspent criminal offences (if any) and sign the declaration
I declare that, at the time of signing this declaration, I have not been convicted of any criminaloffences other than stated above.
Signed
Date

DayMonthYear
Date
I declare that, at the date of signing this declaration I have not been disqualified from working with children or vulnerable adults, or subject to sanctions imposed by a regulatory or professional body e.g. Ofsted, The General Care Council (GSCC) or General Medical Council (GMC).
Signed
Date

DayMonthYear
Date
To the best of my knowledge and belief the information I have given is correct. This information will be treated as confidential and any relevant details will only be made available to another organisation with my permission. Involvement as a volunteer may require reference and/or a Disclosure and Barring Service (DBS) check, if appropriate. I consent to the information on this form being held on file in accordance with the DataProtection Act 1998. I agree to abide by Changing Pathways code of confidentiality.
Signature

Signed
Date

DayMonthYear
Date
Should be Empty:

PART ONE – YOUR DETAILS