Fill Out the Application Form Begin your approved training Enrolment and Learning Agreement CompanyThis field is for validation purposes and should be left unchanged.First NameSurnameGenderMaleFemaleOtherI prefer not to answerEmail Phone NumberDate of birth MM slash DD slash YYYY AddressEmergency contact detailsFirst NameSurnamePhone NumberRelationship to youLearning SupportDisabilityLearning DifficultiesAre you a wheelchair or mobility scooter user?Do you want to share any additional information with us?Attach CVMax. file size: 1 GB. Evidence of IDMax. file size: 1 GB. Photographic IDMax. file size: 1 GB. Courses L3 Enrolment CBT-L5 Enrolment L2 Enrolment L4 - YR1 Enrolment Enrolment and Learning Agreement Form – 2026/2027 Completion of this application does not automatically entitle or guarantee students a place on the courses being advertised, which are subject to entry requirements, minimum student numbers and payment of fees Payment of fees detailed in this application must be completed prior to any session being undertaken for that term. ( see payment section) Enrolment and Learning Agreement Form – 2025 Completion of this application does not automatically entitle or guarantee students a place on the courses being advertised, which are subject to entry requirements, minimum student numbers and payment of fees Payment of fees detailed in this application must be completed prior to any session being undertaken for that term. (See payment section)Enrolment and Learning Agreement Form – 2026 Completion of this application does not automatically entitle or guarantee students a place on the courses being advertised, which are subject to entry requirements, minimum student numbers and payment of fees Payment of fees detailed in this application must be completed prior to any session being undertaken for that term. ( see payment section)Enrolment and Learning Agreement Form – 2026-27 Completion of this application does not automatically entitle or guarantee students a place on the courses being advertised, which are subject to entry requirements, minimum student numbers and payment of fees. Payment of fees detailed in this application must be completed prior to any session being undertaken for that term. ( see payment section)Personal DetailsName MRMRSMISSMsOther MR/MRS/MISS/Ms/Other FIRST NAME Last Gender M/F M F Date of Birth DD slash MM slash YYYY Age on 31/12/25Address DetailsAddressTownCountyPostcodePeriod at address (Yrs & Mths)Contact DetailsTel HomeTel WorkMobile NoEmail address Emergency Contact DetailsLearning SupportFirst nameSurnameTelephone NoRelationship to youDo you have any disabilities, learning difficulty or medical conditions, which may affect your ability to learn?Disability Y N Learning Difficulty Y N Are you a wheelchair user Y N ID: Evidence: Must have 1 x photo and 1 x utilityID: Evidence No 1Max. file size: 1 GB. ID: Evidence No 2Max. file size: 1 GB. Evidence of Learning Capability e.g. portfolio N/AMax. file size: 1 GB. Course Details Course Title Day/Eve Time Start Date Course Code Fee (£) Counselling Studies Weds eve 18.30–21.30 04.03.26 CST – L3 £1,195.00 Counselling Studies Sat, day 9.30–4.00 04.03.26 CST – L3 £1,195.00 Course Details Course Title Day/Eve Time Start Date Course Code Fee £ CBT – L5 Tuesday 6.00 pm to 9.30pm TBA CBT-L5 £2,495.00 Course Details Course Title Day/Eve Time Start Date Course Code Fee (£) Counselling Skills Thursday eve 18.30–21.30 05.03.26 CSK – L2 £995.00 Counselling Skills Sat, day 9.30–4.00 05.03.26 CSK – L2 £995.00 Course Details Course Title Day/Eve Tick as Appropriate Time Start Date Course Code Fee £ Diploma in Therapeutic Counselling Wednesday 10:00 am to 4.30 pm 14.01.2026 TC-L4 £3,495.00 P.A. Employment DetailsName of EmployerAddressContact nameTelephone numberEmail address Length of serviceBackground information– Ethnic origin. It would be helpful for the future provision of courses if you would kindly complete this section: (please tick the box) White- English/ Welsh/ Scottish/ Northern Irish/ British White- Irish White- Gypsy or Irish Traveller White- Any other White background Mixed/ Multiple ethnic group- White and Black Caribbean Mixed/ Multiple ethnic group-White and Black African Mixed/ Multiple ethnic group- White and Asian Mixed/ Multiple ethnic group- Any other mixed/multiple ethnic background Asian/ Asian British- Pakistani Asian/ Asian British- Bangladeshi Asian/ Asian British- Chinese Asian/ Asian British- Any other Asian background Black/ African/ Caribbean/ Black British- African Black/ African/ Caribbean/ Black British- Caribbean Black/ African/ Caribbean/ Black British- Any other Black/ African/ Caribbean background Other ethnic group- Arab Other ethnic group- Any other ethnic group Any other Your learning historyWhen were you last involved in any kind of formal structured learning? <br>Tick highest level achieved. Less than 2 years 2-5 years 6-10 years More than 10 years Unknown Entry level (Certificate in Adult Literacy, ESOL) Entry level (Certificate in Adult Literacy, ESOL) Other qualifications below level 1 Other qualifications below level 1 Level 1 (GCSE/O Levels Grades D-G or below 5 Grades A-C, CSE below 5 Grade 1 or more qualifications than Entry level but less than Full Level 2) Level 1 (GCSE/O Levels Grades D-G or below 5 Grades A-C, CSE below 5 Grade 1 or more qualifications than Entry level but less than Full Level 2) Full Level 2 ( GCSE/O levels (5 or more Grades A-C), CSE grade 1 (5 or more), 1 A level or 2/3 As levels) Full Level 2 ( GCSE/O levels (5 or more Grades A-C), CSE grade 1 (5 or more), 1 A level or 2/3 As levels) Full Level 3 (2 or more A-levels, or more AS levels or Diploma) Full Level 3 (2 or more A-levels, or more AS levels or Diploma) Level 4 (First Degree or Teaching qualification (including PGCE)) Level 4 (First Degree or Teaching qualification (including PGCE)) Level 5 ( Higher Degree, Post Graduate) Level 5 ( Higher Degree, Post Graduate) Other qualification level not known Other qualification level not known Not known Not known No qualifications No qualifications Please tick one box which best describes your situation and where did you find out about this course? Employed full-time (16 hours or more per week) Employed part-time (less than 16 hours per week) Self-employed/small business Unemployed How long have you been unemployed? Years Months Retired Other (please specify) Prior to enrolment were you in full-time education/training? Local Paper Learning venue Brochure Web site Current learner Library Friend/Relative Leaflets/Postcards Other (please specify) Payment details Cheque (Payable to Synergie Counselling Services Limited) Cash Credit card Debit card For instalment plans please see separate agreement Privacy Notice Some of the information you supply will be used by: CPCAB (the awarding organisation associated with your course) in carrying out its functions when verifying your Unique Learner Number and uploading your achievement data (if any) to your Personal Learning Record, thereby fulfilling the requirements of the Skills Funding Agency. The Skills Funding Agency to fulfil its statutory functions, issue/verify your Unique Learner Number (ULN) and update/check your Personal Learning Record. The Skills Funding Agency may share your ULN and Personal Learning Record with other education-related organisations such as your careers service, school, college, university, Government Departments, and public bodies responsible for funding your education. Further details of how your information is processed and shared can be found at: Click here to view the Privacy Notice I understand that in the event I am unable to complete the course, the course fees will still be payable. SignatureDate MM slash DD slash YYYY Please answer the following questions in support of your applicationPayment details All payments to be made to the Synergie bank account by bank transfer. Deposit £300.00 – Payable only after an offer of a place is given at interview. Bank - HSBC A/c Name – Synergie Counselling Services Ltd Sort Code – 40 24 18 A/c No – 41442546 For instalment plans please see separate agreement.1. What is your motivation for enrolling on this course? (200 Words)2. Please explain why you feel this is the right time for you to start this journey taking into account your personal circumstances etc. (200 words)3. How do you feel about entering into further education that will involve writing a weekly journal of approx. 750 words? (200 words)1. What is your motivation for moving on to a level 5 Diploma in CBT? (200 Words)2. Please explain why you feel this is the right time for you to continue your training taking into account your personal circumstances etc. (200 words)3. What was the most challenging aspect of your level 4 training? (200 words)4. How would you describe the group dynamics in your level 4 group, how did you feel about the group? (200 words)5. If you were to highlight one aspect of self-awareness during your level 4 training what would it be? (200 words)6. Any other information you would like to give including a comment on why you feel Synergie would be right for your training needs? (200 words)7. If we were able to offer a Monday as an alternative study day, could you transfer to this day? YES/NO1. What is your motivation for enrolling on this course? (200 Words)2. Please explain why you feel this is the right time for you to start this journey taking into account your personal circumstances etc. (200 words)3. How do you feel about entering into further education that will involve writing a weekly journal of approx. 750 words? (200 words)1. What is your motivation for moving on to a level 4 Diploma in Therapeutic Counselling? (200 Words)2. Please explain why you feel this is the right time for you to continue your training taking into account your personal circumstances etc. (200 words)3. What was the most challenging aspect of your level 3 training? (200 words)4. How would you describe the group dynamics in your level 3 group, how did you feel about the group? (200 words)5. If you were to highlight one aspect of self-awareness during your level 3 training what would it be? (200 words)6. Any other information you would like to give including a comment on why you feel Synergie would be right for your training needs? (200 words)
