Volunteer Counsellor Application Form CompanyThis field is for validation purposes and should be left unchanged.Section 1 : General InformationName(Required) DrMissMrMrsMsProf.Rev. Prefix First Last Best Contact Number(Required)Alternative Contact NumberAddress(Required) Street Address Address Line 2 City ZIP / Postal Code Email Address(Required) Gender(Required)MaleFemaleNon-binaryEthnic Background(Required)Asian IndianAsian PakistaniAsian BritishAsian OtherBlack CaribbeanBlack AfricanBlack BritishBlack OtherMixed – Black Caribbean/WhiteMixed - Black African/WhiteMixed – Asian/WhiteMixed BritishMixed OtherWhite BritishWhite IrishWhite OtherOther – ChineseOther – Chinese/BritishAny OtherPrefer not to sayWe are an equal opportunities organisation. For monitoring purposes only how would you describe your ethnic origin?Age Range(Required)20-2930-3940-4950-5960+Briefly, please tell about any relevant experience, paid or unpaid.(Required)Have you experienced any major bereavements that you feel have had a significant impact on you?(Required) Yes No Have you had a major bereavement in the last 2 years? (If yes, please give brief details)(Required)Are you looking for a placement with Bereft as part of your ongoing counselling and psychotherapy training?(Required) Yes No If yes, please continue to Section 2. If no, please go to Section 3.Section 2 : Counselling PlacementsName of training organisationAddress of training organisationName of your primary tutorWhat is the counselling approach?What year of training are you in?What aspects of grief and bereavement have you covered, either in your training or through CPD?Are you in any other bereavement counselling placement currently? Yes No Have you applied to any other organisations for a placement as a voluntary counsellor? Yes No Are you receiving supervision for your course? Yes No Section 3 : Counselling with BereftOn rare occasions some of our counselling work takes place in clients’ homes. If appropriate, are you willing to work in this way? Please note that this will not affect the outcome of your application.(Required) Yes No Do you have any physical limitations that we should be aware of?(Required) Yes No If yes, please provide details.Are you able to counsel in languages other than English?(Required) Yes No If yes, please provide details.When would you be available for MONTHLY Bereft group supervision? Meetings last 2 hours and are delivered on Zoom or similar. Please tick all those that apply.(Required) Mondays 10:00am Mondays 12:00pm Mondays 6:30pm Tuesdays 5:00pm Tuesdays 7:00pm Wednesdays 7:30pm Thursdays 7:00pm Fridays 10:00am We offer our clients a hybrid bereavement counselling service with sessions delivered either in-person or remotely (online/ telephone). Please confirm that you are able to work this way. Further details can be discussed.(Required) Yes No If there is any other information that you feel we should have about your availability, please share it here.Section 4 : ReferencesPlease provide us with contact details for two references. (If this is for your counselling placement, one of these should be your supervisor or tutor.) First ReferenceName(Required) First Last Address Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email(Required) PhoneSecond ReferenceName(Required) First Last Address Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email(Required) PhoneDBS DISCLOSURE: Do you have a DBS disclosure which is less than 3 years old?(Required) Yes No If no, you will need to obtain one before commencing your placement.If yes, please attach here:Max. file size: 256 MB. Do you have proof of readiness to practice?(Required) Yes No If yes, please attach here:Max. file size: 256 MB. If there is any other information that you feel we should have, please share it here.IMPORTANT INFORMATION FOR TRAINEE COUNSELLORS ON PLACEMENT Please read the following carefully before applying to ensure that BEREFT is an appropriate placement for youTAPING We do not give blanket permission to tape record BEREFT counselling sessions. BEREFT clients will need to give written permission to be taped. CASE STUDIES & EXTERNAL SUPERVISION (PEER OR INDIVIDUAL) Clients must give written permission if counsellors wish to use case study material in their training. There is a set procedure for this. NB: Above points can be discussed in more detail at interview CONFIDENTIAL DISCLOSURE FORM FOR VOLUNTEER COUNSELLORS Because you will be working with vulnerable people, we need you to answer the following question. Please be assured that this is in confidence and will not necessarily exclude you from being a volunteer. Have you ever been convicted of any criminal offence by court of law?(Required) Yes No If yes, supply us with details of the nature of the offence[s] and the date of your conviction[s]:Date of offence statement(Required) I certify that the above statement is a true statement NB: The possession of a conviction will not necessarily debar you from becoming a volunteer counsellor unless Bereft considers that your conviction[s] render you unsuitable. In making this decision we will consider the nature of the offence/how long ago it was committed/what age you were at the time and any other relevant factors. Failure to disclose any criminal offences could result in your application being rejected or immediate termination of your placement. Thank you for your application. When you have submitted your form, a member of the office team will get in touch via email to confirm that we have all the information we need to process your application or follow up on any queries. Δ
