My Desired Start Date:(required)
(date format: mm/dd/year)
Select
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Diploma of Professional Counselling (one year on campus)
Diploma of Professional Counselling (one year correspondence)
Addictions Worker Certificate (24 weeks on campus)
Addictions Worker Certificate (24 weeks correspondence)
Family Support Worker Certificate (24 weeks on campus)
Family Support Worker Certificate (24 weeks correspondence)
Career Exploration & Development Skills Certificate (18 weeks on campus)
Career Exploration & Development Skills Certificate (18 weeks correspondence)
Full Name:
Date of Birth:
Social Insurance Number:
Funding Source:
Street:
City:
Province/State:
Select
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Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Nova Scotia
Nunavut
Northwest Territories
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
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AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
AS
GU
MP
PR
VI
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Postal/ZIP Code:
Country:
Email:
Home Phone Number:
Work Phone Number:
Fax Number:
Occupation:
Gender:
Select
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male
female
Age:
Select
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18-25
26-35
36-50
51-65
over 65
1. What is your reason for wanting to pursue counsellor training?
2. What in your view are some important personal qualities of an effective counsellor?
3. Say briefly how you believe the family of origin influences the kinds of relationships a person has as an adult.
4. What life experiences have you had that will help you to be an effective counsellor?
5. What life experiences have you had that might interfere with being an effective counsellor?
6. How do you rate your written skills at this point? Please comment.
7. Are you an active participant in groups, not so active, usually silent?
8. Are you aware of how your participation affects others in a group? Please explain.
9. Would you describe your personality as laid back or outspoken?
10. How would you describe your role in the family you grew up in?
11. What may be your greatest obstacle(s) to becoming an effective counsellor?
12. How would you describe your degree of interest in pursuing counsellor training?
13. What kinds of problems and what kinds of people would you prefer to help in counselling?
14. What kinds of problems and what kinds of people would you not prefer to help in counselling?
15. Have you found that people tend to come to you to talk about their situation or problems? If so, what is it about you that explains this?
16. Do you believe that a professional counsellor should be involved in his or her own process of personal growth and healing? Please explain.
17. How open to exploring your life experiences are you? Comment/Explanation
18. Have you ever had serious thoughts of suicide? Attempted suicide?
19. Have you ever been prescribed medication for depression or other emotional difficulty?
20. Are you currently involved in any form of psychological treatment? If "Yes", please describe.
21. How do you handle strong criticism and conflict?
22. What support systems will you have for your personal struggles, feelings, needs or issues that may occur during your studies? If so, is it enough?
23. How confident are you in your ability to read course materials and to take notes in class?
24. How confident are you in your ability to understand spoken and written English? To express yourself in spoken and written English?
25. What aspects of your personal background do you consider relevant to your future counsellor training?
26. Rate the importance of the following goals (0-10) (0 lowest 10 highest) :
a) Learn Concepts and Skills
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0
1
2
3
4
5
6
7
8
9
10
b) Develop a career
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0
1
2
3
4
5
6
7
8
9
10
c) Personal Growth
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0
1
2
3
4
5
6
7
8
9
10
27. Give examples of counselling employment you hope to obtain in the future, including any desired specializations, career outcomes (e.g. establishing a recovery program, service agency or private practice).
28. Any Arrests/Charges/Warrants?
29. Have you ever been hospitalized or treated for any psychiatric disorder? Please specify and include a summary of the outcome, current status and your attitude towards these.
30. Are you currently affected by alcohol and drug abuse? Are you now or have you ever been in recovery from alcohol and drug abuse, and if so, for how long?
31. In the past, have you experienced any personal trauma or difficulties? Please specify and include a summary of the outcome, current status and your attitude towards these.
32. Any of the following in the last year?
Divorce
Death in the family
Loss of job/income
Illness
Other personal trauma or difficulty yes / no Please specify:
33. Are you aware of any personal characteristics or difficulties that may make pursuing counsellor training difficult for you at this time? Please elaborate.
34. Do you have the self-discipline required to complete assignments, especially if you are considering correspondence study?
35. Are you committed to fulfillment of course requirements including full attendance, completion of assignments (campus students), and completion of all correspondence course assignments?
36. Are you committed to finishing the program?
37. If you experience significant personal difficulty during your training, for example, suicidal ideas, personal stress and/or substance abuse, you accept that you will be required to discuss with your Faculty Advisor or other experienced counsellor, how this may affect your ability to continue in the program.
38. Education Achieved
University Degrees:
Certificates:
High School:
Other:
39. What types of employment have you had in the past? List your most recent and some past employers, locations, positions, and dates of employment and describe how satisfying this employment was or was not for you and why?
Upon receiving your application, references may be requested.
