ISAT Diploma Application

"*" indicates required fields

Course Location*

Course start date*

Personal details

Your Name*

Title First Last

Home address*

Street Address Address Line 2 City State / Province / Region Post Code

Email address*

Daytime telephone number*

Evening telephone number*

Mobile number

Date of birth*

Nationality*

Gender*

Academic, professional and counselling/therapeutic qualifications*

Awarding body

Name of programme or title of qualification

Type/level

Date of completion

Grade

*Please attach scanned copies of your certificates with this form

Relevant work experience*

Name of employer

Nature of work

From

Full/ part-time

Voluntary counselling/therapeutic work*

Details

Date

Proposed clinical placement

Organisation*

Address*

Street Address Address Line 2 City State / Province / Region Post Code Country

Email*

Telephone number*

Has your placement been confirmed?*

Yes

If your placement will be based on your own private work, please indicate how you intend to achieve this. Please indicate whether you are able to see clients online.

References

Please supply the names and addresses of two people willing to give a reference for you. The referees must not be relatives or in a close personal relationship with you. One should have known you personally for a year or more. One should be someone with whom you have worked in a paid or voluntary capacity. One of the references must be from your current or a very recent clinical supervisor. If you have not already received one, please request a Reference Form from the Laurel Centre to forward to your referees and return to sonia@thelaurelcentre.co.uk.

References*

Name

Address

Post code

Telephone number

Learning support

Do you have any learning difficulties that you feel may affect your ability to gain this qualification? This could be a physical disability, a health problem, or difficulty with English (eg, dyslexia).*

Yes

Please give details*

Is English your first language?*

Yes

Please give details*

Additional information

This field is for validation purposes and should be left unchanged.