Application for TA East London Institute Counselling and Psychotherapy Training Full Name * First Name Last Name Date * MM DD YYYY Preferred Pronouns * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Neurodivergent. Please specify: Neurodivergent. Diagnosis Type: Formal Diagnosis Self Diagnosis Which Course are you applying for? * Foundation Year / Counselling and Psychotherapy Year 1 Counselling and Psychotherapy Advanced Training Counselling and Psychotherapy Year 2 Counselling and Psychotherapy Year 3 Counselling and Psychotherapy Year 4 Clinical Diploma in Supervision Education * Please state your qualifications. References * Please include the the names of the two references one personal and one from a workplace. Reasons for Applying * Say in 200 words why you wish to train with TA EAST. Including work and life experience. I have a disability / health / learning difficulty * Yes No I need to declare a criminal record. * Yes No Thank you for submitting your application. If you experience any issues with this process, please email us.