Counsillor Application General InformationName(Required) First Last Male / Female(Required) Male Female Address(Required) Street Address Address Line 2 City ZIP / Postal Code Tel No (day)(Required)MobileCan a message be left?(Required) Yes No Email(Required) Age(Required) 21 - 30 30 - 45 46 - 60 60+ Ethnic Background We are an equal opportunities organisation. Fot monitoring purposes only how would you describe your ethnic origin?Breifly, why do you want to join Bereft as a counsillor?(Required)Breifly, please tell about any relevant experience, paid or unpaid.(Required)Have you had a major bereavement in the last 2 years? (If yes, please give brief details)(Required)Tell us about your counsilling training & qualifications.(Required)You will need to have completed a counsilling certificate. (Please attach copy below)Max. file size: 256 MB.Are you currently in counselling training & looking for a placement with Bereft?(Required) Yes No Counselling PlacementsPlease give the name & address of where you are training, & the name of your primary tutor(Required)In which year of training are you?(Required) What is the counsilling approach?(Required) Have you covered loss & bereavement?(Required) Yes No Are you in any other bereavement councilling placement currently?(Required) Yes No Have you applied to any other organisations for a placement as a voluntary counsellor?(Required) Yes No If Yes, which? Are you recieving supervision for your course?(Required) Yes No Name of supervisor First Last Contact No.General Information ContinuedDo you have your own transport? (Bereft clients are residents of the Bough of Ealing. How would you travel to see them?)(Required) Some of our counsilling work is undertaken in clients' homes, if appropriate. Are you willing to work in this way?(Required) Yes No We can also accommodate volunteers who can only see clients in an external venue - PLEASE DO STILL APPLYAre you able to climb stairs etc?(Required) Yes No Please tell us any restrictions Are you able to counsel in any other languages other than English?(Required) Yes No Other languages When would you be available for Bereft group supervision? Please tick those which apply(Required) Morning - Monday/Thursday Evening - Monday/Tuesday/Wednesday/Thursday Would you be able to see clients once weekly?(Required) Yes No We expect counsillors to see 3 clients per week, starting with 1 then building up to 3. What is your availability?Weekdays Mornings Afternoons Evenings Weekends Mornings Afternoons Evenings Any other information about your availability ReferencesPLEASE SUPPLY US WITH TWO REFERENCES (if this is for your counsilling placement, one of these should be your supervisor) First Reference (Supervisor / Tutor if applicable)Name(Required) First Last Address Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) PhoneReference PersonalName(Required) First Last Address Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) PhoneDBS (CRB) DISCLOSURE: Do you have a DBS/CRB disclosure which is less than 3 years old?(Required) Yes No Having a DBS/CRB may speed up the applicationIf available, upload DBS/CRB hereMax. file size: 256 MB.Any other information you would like us to haveINPORTANT INFORMATION FOR TRAINEE COUNSILLORS 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 BEREFET counsilling sessions. BEREFT clients will need to give written permission to be taped. CASE STUDIES & EXTERNAL SUPERVISION (PEER OR INDIVIDUAL) Clients must give written permission (there is a set procedure for this) if counsillors wish to use case study material in thei training. NB: Above points can be discussed in more detail at interview CONFIDENTIAL DISCLOSURE FORN FOR VOLENTEER COUNSILLORS Because you will be seeing clients in their own home 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 Date of offence(Required) MM slash DD slash YYYY Details of offence(Required) 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 counsillor 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 commited/what age you were at the time and any other relevant factors, Failure to disclose any criminal offences could lead to either your application being rejected or if you have become a counsillor to immediate release from BERTEFT. Δ
