Secure Application Form

Application Form

1. Course Details

Enter the details of the course you would like to apply for.

Course start date month/year

Day of week

Name and level of course

2. Personal Details

Name as you would like it to appear on a certificate:

Known as (if different):

Title

Gender pronoun

Date of birth

Correspondence address

Postcode

Email address (a copy of this form will be emailed to the address supplied)

Home phone

Mobile phone

Identification

To confirm your identity, please provide a copy of photo ID (e.g driving licence photo page or Passport photo page) by email to enrolments@heartwoodcounselling.org

I will send a copy of my photo ID to enrolments@heartwoodcounselling.org

Learning requirements

Please indicate below if you are aware of any specific learning requirements or difficulties you may have:

Emergency Contact details

Please could you supply us with emergency contact details:

Name:

Relationship:

Mobile number:

Home phone:

Work phone:

3. Entry Requirements

Only applicable if registering for Level 4 or above. Please list the details of your qualifications below (most recent, most relevant and highest level of achievement). Otherwise add N/A and click Next.

Year

Course title and level

Centre

Awarding body

Year

Course title and level

Centre

Awarding body

Year

Course title and level

Centre

Awarding body

Year

Course title and level

Centre

Awarding body

Continue below if necessary

4. Referee / Interview

(Note this information is only required if registering for level 4 or above, if not a level 4 application please enter N/A and click next).

Please provide one independent referee who has known you for at least 2 years (must not be a relation/member of your family. By completing below you confirm that you have permission to share these details.

Referee's name

Capacity in which they know you (not a relation or member of your family)

Their email address

Their phone number

Confirmation of pre-course interview (level 4 Only)

I have completed a pre-course interview and have been accepted I need to arrange a pre-course interview I am not applying for level 4

5. Personal statement and agreement

Have you experienced any mental health issues or significant loss over the last five years (bereavement, illness, relationship break-up etc.). If so, please give details as this may impact upon your training. This information will be held in strictest confidence.

Declaration

I hereby declare that the information I have provided about myself in this application is true and correct.

Consent

I agree to Heartwood Counselling and Psychotherapy Ltd processing the data on this form in accordance with the Data Protection Act 2018.

Your personal data will be used to process your enrolment, support your experience throughout this website, and for other purposes described in our privacy policy.

Terms

I have read and agree to the Terms and Conditions

Application Form

1. Course Details

2. Personal Details

Identification

Learning requirements

Emergency Contact details

3. Entry Requirements

4. Referee / Interview

Confirmation of pre-course interview (level 4 Only)

5. Personal statement and agreement

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