Counsellor Application Form

Counsellor Application Form

This application form is in three sections:

1. Counsellor Information

2. Police Vetting

3. Terms and Conditions
1. Counsellor 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.
Are you a New Zealand-based counsellor?*

YesNo
New Zealand based Counsellor - hidden

No
Which country are you located in?
Criteria for becoming a 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.
- 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; music therapy; or traditional Maori or Pasifika therapies etc, 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 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; 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; music therapy; or traditional Maori or Pasifika therapies etc, 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.
First Name*
Last Name*
Gender identity
You may provide your gender identity here:
Consulting Address

This is the address you practice from and will be provided to potential clients to help them choose a counsellor.
Street Address*
Suburb*
Town/City*
Country
Postcode*
Consulting Add Long text
Phone Number*

Area CodePhone Number
Work Phone

Area CodePhone Number
Email*
example@example.com
Website
Optional
Organisation name
Optional
Other address (optional)
Street (Other)
Suburb (Other)
Town /City (Other)
Country (Other)
Post code (Other)
Delivery type*

OnlineIn PersonBy Phone
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*

Royal Australian and New Zealand College of PsychiatristsThe New Zealand Association of Child and Adolescent PsychotherapistsNew Zealand Association of PsychotherapistsThe New Zealand College of Clinical PsychologistsNew Zealand Psychological SocietyNew Zealand Association of CounsellorsAotearoa New Zealand Association of Social WorkersNew Zealand Christian Counsellors AssociationAddiction Practitioners’ Association Aotearoa - New ZealandAustralian and New Zealand Arts Therapy AssociationThe Psychotherapists Board of Aotearoa New Zealand LtdNew Zealand Psychology BoardOther
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.*

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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?

YesNo
Iwi Affiliation - please select Iwi affiliation(s)

HaurakiKahungunuKati MamoeMorioriMuaupokoNgai TahuNgai TaiNgaiterangiNgai TupangoNga PuhiNgapuhuNga RauruNga RuahineNgati ApaNgati AwaNgati HauaNgati HineNgati KahuNgati Kahungunu Ki TeNgati KonohiNgati KuriNgati MamoeNgati ManawaNgati ManiapotoNgati MaruNgati MutungaNgati PikiaoNgati PoaaNgati PorouNgatiranganuiNgati Raukawa (Waikato)Ngati Raukawa (Wellington)Ngati RuanuiNgati TamaterāNgati Toa (South Island)Ngati Toa (Wellington)Ngati WaiNgati WhakaueNgati WhatuaRangitane (Hawkes Bay)Rangitane (Manawatu)Rangitane (South Island)RongowhakaataTainuiTaranakiTau IwiTe Aitanga A MakakaTe ArawaTe Atiawa (South Island)Te Atiawa (Taranaki)Te Atiawa (Wellington)Ta Ati Hau Nui A PaiTe AupouriTe AwawaTe RarawaTuhoeTuwharetoaWaikatoWhakatohea
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*

AbuseAddictionAnxietyCoping skillsDepressionFamily violenceGrief/lossLife changesSexual abuseTrauma/PTSDChildren/YouthRelationshipsPlay TherapyOther
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, suicide related, children)*

NoYes
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.?*

YesNo
GST. hidden

YesNo
2. Police Vetting

Victim Support vet potential counsellors to help ensure the safety of clients who wish to receive counselling 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.
2. Police Vetting

Victim Support vet potential counsellors to help ensure the safety of clients who wish to receive counselling services. The information provided in this section is for vetting purposes only. It is not viewable by Victim Support frontline staff or clients.
If you have completed Police Vetting within the last 12 months, a copy of the result can be submitted with this application and no further Police Vetting information is needed. (Note: A Ministry of Justice letter is NOT sufficient)

Upload your completed Police Vetting here
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If you do NOT have a completed POLICE VETTING (with 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:

Same as "Consulting Address"Same as "Other Address"Different than both the above
Permanent Residential Address

Street Address

Suburb

Town/City/Rural Area

Postal Code
NZ Driver Licence number:
*Used for Police Vetting
Have you ever been known by any previous name(s)?*

YesNo
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?*

YesNo
Please provide details:
Are there are charges against you yet to be heard?

YesNo
Please provide details:
I have lived in Australia over the last 10 years

YesNo
Australian Police Vetting Consent Section:

If you have lived in Australia over 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/user-guide-to-pvs-vetting-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 a registered Victim Support Counsellor to Victim Support. I understand that Victim Support is making this request for the purpose of assessing my suitability as a counsellor for Victim Support clients.

Yes
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)*

Drivers' LicencePassportA photo of you holding your photo ID
* 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

Student IDBirth CertificateUtilities Bill addressed to you not less than 6 months earlierDrivers' LicencePassportOther
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:*

YesNo
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A Counsellor Application Form has been submitted
Should be Empty:

1. Counsellor Information

Consulting Address

Other address (optional)

2. Police Vetting

2. Police Vetting

Evidence of Identity

3. Terms and conditions