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Applying for

Title

First name

Surname

Address

Postcode

Telephone number

Email address

Please confirm you are eligible to work in the UK ?

Yes

Do you consider yourself to have a disability or condition? If so, please specify

Please list any requirements you will need for your placement

Role you are applying for

Locations you would consider a placement in

Counselling Qualifications and Training

Professional membership number

Are you on the Children Workforce DBS update system?

Yes

Do you currently have a valid insurance certificate?

Yes

Number of supervised counselling hours

Additional training relevant to working with young people

Please list the Name, Job Title, Telephone Number and Email Address of your first reference (must be tutor or supervisor)

Please list the Name, Job Title, Telephone Number and Email Address of your second reference

Days you can commit to on a weekly basis

I am able to commit to

a school day

I am able to commit to one year on placement

Yes

Supporting statement and additional information

Please attach any relevant documents such as qualification certificates

How did you hear about London Young Counselling?

Signature

Date