APPLICATION FORM
FOR CPCAB LEVEL 4 DIPLOMA IN
PERSON-CENTRED THERAPEUTIC COUNSELLING, Sept 2016
PERSONAL DETAILS
Surname:
Title:
Forename (in full):
Preferred name:
Date of birth:
Nationality:
Country of birth:
CONTACT DETAILS
Home address:
Address for correspondence (if different):
Home telephone number:
Mobile number:
E-mail address:
COMPLETED APPLICATION FORM AND REFERENCES SHOULD BE RETURNED TO:
Lynne Dowson
Counselling Department
Swarthmore Education Centre
2-7 Woodhouse Square
Leeds
LS3 1AD
Email: [email protected]
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EDUCATION AND QUALIFICATIONS
School, College, University or
educational establishment
Dates
From
To
Qualifications gained or being
studied for
Date obtained
result and grade
TRAINING - Professional / Occupational / Equal Opportunities
Training establishment
Course attended or qualifications gained
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PAST EMPLOYMENT HISTORY
This section is for brief details about your past employment history. Please include any part-time, casual and
voluntary work undertaken.
Dates
From - To
organisation name, address
and telephone number:
Position held and brief description of duties
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CURRENT EMPLOYMENT
Post title:
Date commenced:
Organisation name, address & telephone number:
Details of post:
QUESTIONS
1. Please describe in detail your current opportunities for using counselling skills. If you do not have
current opportunities for practice, please describe any earlier practice opportunities you may have had
and give details of your plans for future use of counseling skills).
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2. Please explain your own view of your present strengths and weaknesses in the role of helper/counselor.
3. Please discuss your reasons for wanting to embark on this course at this time in your life.
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4. Please discuss the ways in which the core theoretical model of the course (the person-centred
approach) relates to your own personality and experience (do not hesitate to comment on the ‘conflict’
as well as the ’fit’).
5. Please give your thoughts about the financial and time commitments of the course in relation to your
current life.
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6. What makes you confident about being able to cope with the extensive reading and writing involved in
this course?
7. Describe any previous/current experience you may have of being a client, both in terms of the amount
of that experience and in its influence upon your decision to apply for this training.
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8. Please use this space to write anything else in support of this application, or anything which you would
want us to know about you. Include information such as personal qualities, life experiences, relevant
experiences not referred to elsewhere in the form. Also, include here any health or personal factors
which you consider the college should be aware of when considering your application. You may attach
an additional sheet if you wish.
DECLARATION SIGNATURE
I certify that all the entries are correct and I undertake, if admitted, to observe the
regulations of Swarthmore Education Centre.
Signature …………………….…………………………………….
Date ………………………….
REFERENCES
You are required to submit references from two referees. Forms are attached for your referees to complete.
References should reflect on any experiences and/or qualifications shown in the application form. One of
your referees should be a tutor from the Certificate in Counselling Studies course you attended.
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Reference
Note to referee: Please either return your reference to the applicant in a sealed envelope to be
forwarded with their application, or return directly to the course tutors.
Name of applicant:
Name of referee:
Post/occupation
How long have you known the applicant:
Relationship to applicant:
Address:
Telephone number:
Fax number:
E-mail
Please comment on the applicant’s personal qualities and general character.
Please comment on the applicant’s reliability, personal integrity and honesty.
Please comment on the applicant’s relationships with others / peers.
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Please comment on the applicant’s ability to work in a group / team working.
What do you regard as the applicant’s significant strengths and limitations in relation to studying
on a Diploma in Therapeutic Counselling?
Any additional information:
Referee’s signature: …………………………………….………………
Date: …………………….....
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Reference
Note to referee: Please return your reference to the applicant in a sealed envelope to be
forwarded with their application, or return directly to the course tutors.
Name of applicant:
Name of referee:
Post/occupation
How long have you known the applicant:
Relationship to applicant:
Address:
Telephone number:
Fax number:
E-mail
Please comment on the applicant’s personal qualities and general character.
Please comment on the applicant’s reliability, personal integrity and honesty.
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Please comment on the applicant’s relationships with others / peers.
Please comment on the applicant’s ability to work in a group / team working.
What do you regard as the applicant’s significant strengths and limitations in relation to studying
on a Diploma in Therapeutic Counselling?
Any additional information:
Referee’s signature: …………………………………….………………
Date: …………………….....
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