Relate Northern Ireland 3rd & 4th Floors, 3 Glengall Street, Belfast BT12 5AB APPLICATION FOR RELATE NI THERAPEUTIC COUNSELLING SUPERVISION LEVEL 6 CERTIFICATE (CPCAB) PRIVATE & CONFIDENTIAL SECTION 1: PERSONAL DETAILS (PLEASE FILL ALL FIELDS IN BLOCK CAPITALS) Title: First Name: Surname (Block Letters): Home Address: Telephone Number(s): Mobile Number: Email: SECTION 2: CURRENT & PAST EMPLOYMENT (please continue on separate sheet if required) Please provide details of your work experience including your experience of counselling and supervision with your most recent experience/employment first, including non-therapeutic supervision such as supporting colleagues as a line manager or co-ordinator. Dates Name of employer, address, and Position held Brief description of duties nature of business (paid or voluntary) From To Please tick all of the entry requirements that you meet. SECTION 3: ENTRY REQUIREMENTS At least 450 hours of counselling and therapeutic experience with clients YES/NO Note: Complete Appendix A Qualified at Diploma level or higher for at least 2 years YES/NO Note: Attach copy of relevant Diploma/Certificate Applicant is currently counselling and receiving supervision for counselling work YES/NO how long you have been working Recommendation letter from your supervisor (including YES/NO with supervisor) Applicant is responsible for arranging appropriate supervisees (agreed at readiness to YES/NO practice interview) Applicant is responsible for arranging appropriate Supervisory Supervision (agreed at YES/NO readiness to practice interview)
Relate Northern Ireland 3rd & 4th Floors, 3 Glengall Street, Belfast BT12 5AB APPLICATION FOR RELATE NI THERAPEUTIC COUNSELLING SUPERVISION LEVEL 6 CERTIFICATE (CPCAB) PRIVATE & CONFIDENTIAL SECTION 1: PERSONAL DETAILS (PLEASE FILL ALL FIELDS IN BLOCK CAPITALS) Title: First Name: Surname (Block Letters): Home Address: Telephone Number(s): Mobile Number: Email: SECTION 2: CURRENT & PAST EMPLOYMENT (please continue on separate sheet if required) Please provide details of your work experience including your experience of counselling and supervision with your most recent experience/employment first, including non-therapeutic supervision such as supporting colleagues as a line manager or co-ordinator. Dates Name of employer, address, and nature of business Position held Brief description of duties (paid or voluntary) From To SECTION 3: ENTRY REQUIREMENTS Please tick all of the entry requirements that you meet. At least 450 hours of counselling and therapeutic experience with clients Note: Complete Appendix A YES/NO Qualified at Diploma level or higher for at least 2 years Note: Attach copy of relevant Diploma/Certificate YES/NO Applicant is currently counselling and receiving supervision for counselling work YES/NO Recommendation letter from your supervisor (including how long you have been working with supervisor) YES/NO Applicant is responsible for arranging appropriate supervisees (agreed at readiness to practice interview) YES/NO Applicant is responsible for arranging appropriate Supervisory Supervision (agreed at readiness to practice interview) YES/NO