Counsellor/Rongoā Practitioner Application Form

Counsellor/Rongoā Practitioner Application Form

This application form is in three sections:

1. Counsellor/Rongoā Practitioner Information

2. Police Vetting

3. Terms and Conditions
1. Counsellor/Rongoā Information

The information given in this section may be shared with Victim Support frontline staff and clients in the interests of matching clients with suitable counsellors/rongoā practitioners.
Please select if you are registering as a counsellor (individual registration only) or a rongoā practitioner (register as the principal of an organisation or an individual)
Enter your Healthpoint website link showing you/your organisation is ACC registered:
Are you a New Zealand-based counsellor/rongoā practitioner?
New Zealand based Counsellor/Rongoā practitioner - hidden
Which country are you located in?
Criteria for becoming a registered VAS counsellor with Victim Support:

You must:
- practice counselling; and
- hold a current Annual Practising Certificate (APC) for counselling with a recognised professional body within country of practice. We do not accept Student/Intern status
If you do not practice counselling as your main practice area but you are qualified in other relevant areas of expertise such as social work with counselling components; child play or music therapy; registration will only be considered on a case-by-case basis. These therapies currently also require an APC with a recognised professional body within country of practice.

Police Vetting results relevant to 'in country' requirements are required to be provided to Victim Support. Examples include (but are not limited to) - Police and Character Clearance Report (Australia), Certificate of Good Conduct or Lack of a Criminal Record (USA).
Criteria for becoming a registered rongoā practitioner with Victim Support:

You must:
- practice rongoā; and
- be a registered ACC provider of rongoā services.
Police Vetting results relevant to 'in country' requirements are required to be provided to Victim Support. Examples include (but are not limited to) - Police and Character Clearance Report (Australia), Certificate of Good Conduct or Lack of a Criminal Record (USA).
Criteria for becoming a VAS registered counsellor with Victim Support:

You must:
- practice counselling;
- hold a current Annual Practising Certificate (APC) for counselling with a recognised professional body within country of practice. This includes NZAC/ANZASW/DAAPANZ. We do not accept Student/Intern status); and
- be Police vetted with a 'no results' report.
Note: If you are not a member of a recognised professional body please DO NOT continue this application process. Please reach out in the first instance by email to counselling@victimsupport.org.nz
- If you do not practice counselling as your main practice area, but you are qualified in other relevant areas of expertise such as social work with counselling components; child play; or music therapy; registration will only be considered on a case-by-case basis. These therapies currently also require an APC with a recognised professional body within country of practice.
Criteria for becoming a registered rongoā practitioner with Victim Support:

You must:
- practice rongoā;
- be a registered ACC provider of rongoā services; and
- be Police vetted with a 'no results' report.
Practitioner details
First Name
Last Name
Gender identity
You may provide your gender identity here:
Phone Number

Area CodePhone Number
Work Phone

Area CodePhone Number
Email
example@example.com
Website
Optional
Organisation name(for principals registering a rongoā organisation) or enter your full name again (if registering for an individual rongoā practitioner).
Consulting Address

This is the address you (and in the case of an organisation where practitioners') practice from and will be provided to potential clients to help them choose a counsellor/rongoā practitioner.
Street Address
Suburb
Town/City
Country
Postcode
Consulting Add Long text
Other address (optional)
Street (Other)
Suburb (Other)
Town /City (Other)
Country (Other)
Post code (Other)
Delivery type
Delivery Type long text
Availability - please provide all days and times you are available for clients
Availability long text
(Weekdays/Weekends/Hours/online/face to face)
Please indicate where your Annual Practicing Certificate is issued from below
Other Professional Body Membership:
Professional Body Memberships long text
Please enter the expiry date of your most current valid APC (Annual Practicing Certificate):

DayMonthYear
Date
Upload evidence of current APC from a recognised professional body (a photocopy of your current practicing certificate is acceptable). Note: Membership Certificate is NOT acceptable. We do not accept Student/Intern status

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Ethnicity
Note: Sometimes victims want to see counsellors of the same ethnicity or Iwi. This information may be provided to clients to assist them choosing a counsellor.
Iwi Affiliation - would you like to inform us of any Iwi affiliations?
Iwi Affiliation - please select Iwi affiliation(s)
Iwi Affiliation long text
If you are fluent in any languages other than English, please list below:
Please list all other languages, separated by a comma.
Areas of Expertise/Interest
Please provide details of other relevant Areas of Expertise/Interest:
Areas of Expertise/Interest long text
Are there any types of referrals you do not wish to receive? (i.e. homicide, children)
If so, please detail

please separate types with a comma eg. "text1,text2"0/250
Fee (NZD) ex GST. charged per session
Are you registered for GST.?
GST. hidden
2. Police Vetting

Victim Support vet potential counsellors/rongoā practitioners to help ensure the safety of clients who wish to receive counselling/rongoā services. The information provided in this section is for Police Vetting purposes only. It is not viewable by Victim Support frontline staff or clients. The information requested is required by New Zealand Police to be inputted into a form by Victim Support so that Police can complete vetting on Victim Support's behalf. Please note: the Police process is outside of the control of Victim Support and can take up to 6 weeks.
If you have completed Police Vetting within the last 12 months, a copy of the result can be submitted with this application. (Note: A Ministry of Justice letter is NOT sufficient). There may be times that further information will be requested if this is supplied - you will hear back from Victim Support if this is the case.

Upload your completed Police Vetting here
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If you do NOT have a completed POLICE VETTING (within the last 12 months), please fill in the Police Vetting information fields below.

Police Vetting Information:

Further information regarding the Police Vetting process can be found here. https://www.police.govt.nz/advice-services/businesses-and-organisations/nz-police-vetting-service

Following the receipt of your Police Vetting result, Victim Support will note on its records that vetting was completed and the result. The other Police vetting information that you have submitted (other than your identity details for registration records) will be deleted.
Date of Birth

DayMonthYear
Date
City/Town of Birth
Country of Birth
Permanent Residential Address:
Permanent Residential Address

Street Address

Suburb

Town/City/Rural Area

Postal Code
NZ Driver License number:
*Used for Police Vetting
Have you ever been known by any previous name(s)?
First Name (Previous Name #1)
Last Name (Previous Name #1)
ID confirming Previous Name #1

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First Name (Previous Name #2)
If you have been known by a second previous name please enter it here
Last Name (Previous Name #2
If you have been known by a second previous name please enter it here
ID confirming Previous Name #2

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First Name (Previous Name #3)
If you have been known by a third previous name please enter it here
First Name (Previous Name #3)
If you have been known by a third previous name please enter it here
ID confirming Previous Name #3

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First Name (Previous Name #4)
If you have been known by a third previous name please enter it here
Last Name (Previous Name #4)
If you have been known by a third previous name please enter it here
ID confirming Previous Name #4

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Criminal and Driving Record Information
Please note Police Vetting is subject to the Criminal Records (Clean Slate) Act 2004

Under the Criminal Records (Clean Slate) Act 2004, you do not need to declare a New Zealand conviction if all of the following apply:
• It has been 7 or more years since your most recent conviction and you have not re-offended; and
• You have never had a custodial sentence imposed upon you (including detention at home, in hospital or at any secure facility); and
• You have paid any fines/costs/compensation/reparation.

However, regardless of how long ago you were convicted, you are not eligible to conceal your conviction if:
• You have ever been convicted of a sexual offence; or
• You have ever been disqualified from holding a driver license for repeat offending involving alcohol/drugs; or
• The conviction was from overseas.
Have you ever been convicted of a crime in New Zealand or in any other country?
Please provide details:
Are there are charges against you yet to be heard?
Please provide details:
I have lived in Australia within the last 10 years
Australian Police Vetting Consent Section:

If you have lived in Australia within the last 10 years, you will need to undergo an Australian Police Vetting check. This information will be forwarded to the Australian Police to enable this to occur.
Australian driver’s licence no:
Issued in which Australian State?
Residential Address in Australia:
Street
Suburb
City/Town/Rural District
State
Postal Code
Applicant’s consent to release information:

Please read the Consent for Police Vetting here:

https://www.police.govt.nz/sites/default/files/publications/nz-police-vet-request-consent-form.pdf
I have read and understood the Consent for Police Vetting.pdf. I authorise New Zealand Police to disclose any personal information it considers relevant to my application to be VAS registered counsellor/rongoā practitioner. I understand that Victim Support is making this request for the purpose of assessing my suitability as a counsellor/rongoā practitioner for clients funded for counselling/rongoā through the Victim Assistnace Scheme administered by Victim Support.
Please upload your resident country Police Vetting (or equivalent) documentation here:

This documentation must be signed no more than 90 days prior to submitting
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Evidence of Identity
To be satisfied that we know who you are, you will need to provide the following:
- Copies of TWO forms of ID (one must be photographic)
  AND
- a photograph of you holding your photographic ID.
Primary Identification (including photograph)
* Please provide head and shoulders photograph without glasses. Name and ID number of the photographic ID must be clearly legible.
Upload digital copy of Primary Identification

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Holding your Primary Identification

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Secondary Identification
Upload digital copy of Secondary Identification:

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3. Terms and conditions
Please read our Terms and Conditions here before continuing:
I have read and agree to the terms and conditions linked above:
Signature
Please verify that you are human
A Counsellor/Rongoā practitioner Application Form has been submitted
Should be Empty:

1. Counsellor/Rongoā Information

Practitioner details

Consulting Address

Other address (optional)

2. Police Vetting

Evidence of Identity

3. Terms and conditions