Send Email To 

Your Name 

Your Email 

Building Name / Number 

Street 

Area 

Town / City 

Postcode 

Date of Birth 

Telephone (work) 

Telephone (home) 

Telephone (mobile) 

Current work situation (include voluntary work where relevant): 

Relevant professional & educational qualifications & experience: 

Experience of any previous or current personal therapy, and (if you wish) name of therapist: 

Current Supervision - Supervisor name and qualifications 

Frequency of supervision 

Ratio of supervision to contract work 

Please tick one or more of the following as appropriate: 

COSCA qualifications 

These modules were completed at (name of institution) 

When were modules completed (year) 

Name of Course Director 

APL 

Note: Possession of a COSCA Certificate in Counselling Skills gives the right of exemption from Part 1 of this Diploma (except for the Augmentation). However, in some cases it may be advisable for the applicant to repeat Module 4 here, along with the Augmentation. Please consult the Course Director.  

Reasons for applying for the course. Please provide a 350-500 word statement describing your reasons for applying and how you arrived at this point. 

Names, addresses and telephone numbers of TWO refererees who know your work and potential to train as a Counsellor. (Note: The first reference should be someone who has been your trainer, teacher or manager) 

Referee 1 - Name 

Referee 1: Building / Street No 

Referee 1 - Street 

Referee 1 - Area 

Referee 1 - Town/City 

Referee 1 - Postcode 

Referee 1 - Tel No (home or business) 

Note: The second referee may be a colleague who knows you personally. 

Referee 2 - Name 

Referee 2 - Building / Street No 

Referee 2 - Street 

Referee 2 - Area 

Referee 2 - Town/City 

Referee 2 - Postcode 

Referee 2 - Tel No (home or business)