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APPLICATION FORM
Personal Details
Name*
First
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Tel No. (Home)
Mobile*
Email*

Training & Qualifications
Date (From - To) Course Title Training Establishment Qualification or date due to qualify
Employment
Date (From - To) Job Title Employer Main Duties
Voluntary Work
Date (From - To) Volunteer Position Voluntary Organisation
Teaching Experience
Date (From - To) School Subjects

Clinical Supervisor:
Name
First
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Tel No
Email
Are you willing to have an enhanced DBS check?*
- Yes
- No
Please tell us why you would like to volunteer at The Leicester Counselling Centre and what qualities and experience you would be able to bring:*
What is your availability to see clients at the Centre:*

Referees – one of whom should be able to comment on your clinical knowledge and experience:
1. Name*
First
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Tel No:*
Email:*
Can we contact this referee before your interview:*
- Yes
- No
In what capacity is this person known to you?*
2. Name*
First
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Tel No:*
Email:*
Can we contact this referee before your interview:*
- Yes
- No
In what capacity is this person known to you?*

Our friendly team are always happy to answer your questions! Contact Us

Date (From - To)	Course Title	Training Establishment	Qualification or date due to qualify

Date (From - To)	Job Title	Employer	Main Duties

Date (From - To)	Volunteer Position	Voluntary Organisation