Professional Course in Psychotherapy Application Form

Professional Training Course in Counselling & Psychotherapy

Commencing October 2007

APPLICATION FORM

*Required

Personal Details
Name:	*
E-Mail:	*
Address:	*


Date of Birth:	*
Phone No. (Daytime):	*
Phone No. (Evening):	*

Education

Institution:	*
Course:	*
Year of Commencement:	*
Year of Completion:	*
Qualification:



Institution:
Course:
Year of Commencement:
Year of Completion:
Qualification:



Institution:
Course:
Year of Commencement:
Year of Completion:
Qualification:

Work Experience

Employer:	*
Position/Job:	*
Dates of Employment:	*



Employer:
Position/Job:
Dates of Employment:



Employer:
Position/Job:
Dates of Employment:



Employer:
Position/Job:
Dates of Employment:

Psychotherapy Experience (if any) experience of receiving psychotherapy

Personal Development Courses etc. attended for personal development

Date:
Title of Course:
Facilitated by:



Date:
Title of Course:
Facilitated by:



Date:
Title of Course:
Facilitated by:

Referees
Please supply the names and addresses of two referees, who must not be relatives
Referee Name:	*
Address:	*

Position:	*



Referee Name:	*
Address:	*

Position:	*

Personal Statement (About 200 words)
Please indicate why you wish to be considered for this course, how you have come to apply and if successful what you would hope to do on completion of the course.

This application form is also available to download & print off

There will be an interview for which a fee of €35 will be charged.

Write or phone:

The Secretary,
Tivoli Institute, 24 Clarinda Park East, Dun Laoghaire, Co. Dublin
Telephone: (01) 2809178
e-mail: tivoliinstitute@gmail.com