First Name*

Surname*

Address*

Phone Number*

Email Address*

What is the name of your institution or training provider?

What is the name of your course? Please also tell us what level course it is and what accreditation (if any) it has.

Have you had or are you having any personal therapy? Is this a requirement of your course?

Relevant experience: please tell us about any work or voluntary experience you have had which is relevant to either counselling or to working with victims and survivors of domestic abuse.

Why would you like to undertake a counselling placement with West Mercia Women’s Aid?

Availability: which of our locations would you be able to work from? Availability: which of our locations would you be able to work from? HerefordWorcesterKidderminsterTelford

Availability: what days would you be available to work and how many hours could you offer per week? (Please note that our service operates Monday-Friday 9-5)

When would you be available to start a placement?

How many hours are you required to complete for your training and when do these need to be completed? (Please note we ask for a minimum commitment to our service of 12 months, regardless of when compulsory hours are completed.)

Do you have Professional Indemnity Insurance in place? (Please note it is your responsibility to organise this and it must be in place before you start seeing clients.) Do you have Professional Indemnity Insurance in place? (Please note it is your responsibility to organise this and it must be in place before you start seeing clients.)YesNo

Do you have any physical or mental health issues we should be aware of, or is there any action WMWA would need to take in order to keep you safe and comfortable when you volunteer?

We will treat typing your name in the box below as a digital signature.