Application Form

APPLICATION OPTIONS:

Please select your application choice below:

Certificate in Adoption Support Counselling

Content Warning

I have read and understood that some of the material contained in this course may be emotionally distressing.

PERSONAL DETAILS:

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Title

First Name(s)

Last Name

Address Line 1

Address Line 2

Town/City

County

Post Code

Daytime Telephone

Evening Telephone

Mobile Telephone

Email

EDUCATION & QUALIFICATIONS:

Please provide a brief summary of your education and qualifications.

N.B. FOR THIS COURSE YOU MUST HAVE AT LEAST A LEVEL 4 OR 5 COUNSELLING / PSYCHOTHERAPY QUALIFICATION OR EQUIVALENT TO BE CONSIDERED.

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Education List

Start & End Dates (Month/Year)	Institution	Location	Subject	Qualification(s)

RELEVANT EMPLOYMENT (MOST RECENT FIRST):

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Employment History

Name & Address of Employer	Start & End Dates (Month/Year)	Occupation & Responsibilities

* EXPERIENCE:

Below, please give the fullest details available of your experience as a practising counsellor / psychotherapist. This should consist of at least 100 hours, including placement hours whilst a student (number of hours, dates, supervision arrangements, types of client worked with, employment / voluntary / agency / placement):

Experience

* REASONS FOR APPLICATION:

Please explain why you wish to undertake this course and what you hope to gain from it. This is an important section in helping us to assess your application.

Reasons for Application

SUPERVISOR'S REFERENCE:

In order to qualify for this course, you will need to provide a reference from your current supervisor by supplying the following:

Supervisor's First Name(s)

Supervisor's Last Name

Supervisor's Qualifications

Supervisor's Email Address

Details of Current Supervision Arrangements

THE ALBANY CENTRE requires this information for education purposes and equal opportunities monitoring, your personal data will be processed in accordance with the current Data Protection legislation. This information will not be disclosed to any unauthorised parties.

Please select your preferred session below:

Wed 25th September 2024 (7pm to 9pm)

Tue 29th October 2024 (1pm to 3pm)

I unable to attend either session (you will therefore be invited to a future date)

ZOOM SESSION:

We strongly advise that, as part of the course, you attend one Zoom session. The Zoom session is not compulsory but provides an opportunity to ask questions about being an adoption counsellor and to address any queries you may have arising from the course. It will be hosted by two adoption therapists.

DECLARATION:

Please complete the following declaration by ticking the box and completing the remaining information:

I declare the following:

This completed application and contents for the Certificate in Adoption Support Counselling course contains only true and accurate information.

Signature

Date

Please complete the application form below for the Certificate in Adoption Support Counselling Training.

Warning: you may find some of the material contained in this course emotionally distressing.

APPLICATION OPTIONS:

PERSONAL DETAILS:

EDUCATION & QUALIFICATIONS:

RELEVANT EMPLOYMENT (MOST RECENT FIRST):

* EXPERIENCE:

* REASONS FOR APPLICATION:

SUPERVISOR'S REFERENCE:

Ethnicity *

ZOOM SESSION:

DECLARATION:

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