PEER SUPPORT WORKER TRAINING APPLICATION
PERSONAL DETAILS
*Surname/Family
Name
Home Telephone
*First Names
Mobile Telephone
Title
Work Telephone
Email Address
Address
UK National
Insurance No
Are you a United Kingdom (UK), European
Community (EC) or European Economic Area

Yes

No
(EEA) National?
Please select the category that relates to your current immigration status. This status will be subject to checking
before interview.
 HSMP/Tier 1
 Clinical attachment visa

Work Permit/Tier 2
 Indefinite Leave to remain/enter
 Student

Tier 5 Temporary Worker
 Post Graduate Doctors and
 Visitor

Refugee
Dentists
 Working Holiday

Other, please specify below
 Dependant / Spouse visa
Visa/Tier 5 Youth Mobility
Please supply details of any visa currently held, including number, start/expiry dates and details of any restrictions.
Visa No:
Start Date: (DD/MM/YY)
Expiry Date: (DD/MM/YY)
Details of Restriction:
Does your visa have a condition restricting employment or occupation
in the UK?
If you have a disability, do you require any reasonable adjustments to
be made during the course application process, including interview?

Yes

No

Yes

No
If yes, please supply details:
Please indicate if you have or have had any
previous engagement with secondary mental
health services:


Currently engaged 
No previous engagement
History of engagement
Education & Professional Qualifications Include in this section all the relevant qualifications. All qualifications
disclosed will be subject to a satisfactory check.
Subject/Qualification
Place of Study
Grade/result
Year
TRAINING COURSES ATTENDED. Include in this section any relevant training courses that you have attended or
details of courses that you are currently undertaking. Please also indicate subjects currently being studied.
Course Title
Training Provider
Duration
Date Completed
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PEER SUPPORT WORKER TRAINING APPLICATION
WORK/EMPLOYMENT HISTORY (including voluntary work). Please record below the details of your current or
most recent employer
Employer
Name
Address
Job Title
Grade
From Date
To Date (if
applicable)
Reason for leaving (if applicable)
Description of your duties and responsibilities
PREVIOUS EMPLOYMENT. Please record below the details of your previous employment, beginning with the most
recent first. If required, please provide additional information regarding your employment history on a separate sheet
(or in the space provided on page 4).
Previous Employer 1
Employer
Name
Address
Job Title
Grade
From Date
To Date (if
applicable)
Reason for leaving (if applicable)
Description of your duties and responsibilities
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PEER SUPPORT WORKER TRAINING APPLICATION
SUPPORTING INFORMATION
In this section we want to know your reasons for applying to attend this training course. This can include relevant
skills, knowledge, experience, voluntary activities and training etc. Please continue on a separate sheet if required (or
in the space provided on page 4)
Please explain your experiences of living with a mental health condition
Why are you interested in undertaking this Peer Support Worker course?
What skills and attributes do you think you can bring to this course?
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PEER SUPPORT WORKER TRAINING APPLICATION
Additional Space: Please use this space to continue any answers.
DECLARATION
The information in this application form is true and complete. I agree that any deliberate omission, falsification or
misrepresentation in the application form will be grounds for rejecting this application or subsequent course enrolment.
I understand that completion of this application form and, if successful, subsequent enrolment on the Peer Support
programme, does not form an offer of employment (conditional or otherwise).
Enrolment onto the Peer Support Worker Programme requires undertaking a disclosure and barring service check . I
consent that the organisation can undertake this check and that enrolment onto the Peer Support Worker programme
will be conditional subject to satisfactory clearance.
I agree to the above declaration
Signature
Name
Date
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