Counsellor Application Form
Criteria for becoming a registered counsellor with Victim Support:

Hold a current certificate of membership to a recognised professional body such as NZAC/NZPA/ANZASW/DAAPANZ.

If you are not a member of a recognised professional body but have the required qualifications, skills and experience your application maybe considered on a case by case basis.

• Relevant tertiary qualification or qualifications as set by the applicant’s professional body

• Other relevant qualifications in areas such as social work with counselling components; child play; music therapy or traditional Maori or Pasifika therapies etc. will be considered on a case-by-case basis.

• A completed referee form from the applicant's current or recent clinical supervisor.

• A ‘No Results’ police vetting report.
Are you a New Zealand-based counsellor?*

YesNo
What country are you based in?
First Name*
Last Name*
Consulting Address
Street Address*
Suburb*
Town/City*
Postcode*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Delivery type*

OnlineIn PersonBy Phone
Delivery Type long text
Availability*
Availability long text
(Weekdays/Weekends/Hours/online/face to face)
Professional Body Memberships

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 BoardAddiction Practitioners Association of AotearoaOther
Other Professional Body Membership not listed above?
Professional Body Memberships long text
Please enter the expiry date of your most current practising certificate*

MonthDayYear
Date
Ethnicity
Note: Sometimes victims want to see counsellors of the same ethnicity or Iwi, and this helps Victim Support match victims to the counsellor that suits their need.
Iwi Affiliation
Note: Sometimes victims want to see counsellors of the same ethnicity or Iwi, and this helps Victim Support match victims to the counsellor that suits their need.
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

AbuseAnxietyCoping skillsDepressionFamily violenceGrief/lossLife changesSexual abuseSuicideTrauma/PTSD
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
The fee (NZD) charged per session (max. $200 per hour)*
Documentation you need to include with this application:
Evidence of current membership of an approved professional body (a photocopy of your current practicing certificate is acceptable) *

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A completed VAS Counsellor Referee Check Form from your current or most recent clinical supervisor.
You can download the VAS Counsellor Referee Check Form here
Upload your completed VAS Counsellor Referee Check Form from your current or most recent clinical supervisor here.*

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Police vetting
You are also required to complete a Victim Support Police Vetting Form.

This form is available here: Victim Support Police Vetting Form.

Once the vetting form is submitted to NZ Police for processing it may take up to 6 weeks for a response to come back.

If you have completed police vetting within the last 12 months a copy of the result can be submitted with this application.
Upload your completed Victim Support Police Vetting Form here.*

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Photo ID
You must also provide evidence of your identity:

• your New Zealand driver licence, or
• your current New Zealand passport.
Upload your photo ID here*

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Terms and conditions
I agree that in submitting this application:

• I have provided all the material asked for and that Victim Support may check my
memberships with the relevant organisations annually or as required.

• Victim Support may contact my referee to discuss my application and my suitability for the work I have sought approval for.

• I understand that my details will be held on file by Victim Support and may be provided to the Ministry of Justice as part of compliance reporting.
If approved as a Victim Support counsellor:

• I will send a copy of my new practicing certificate each year to VAS Administrator, NZ Council of Victim Support, PO Box 3017, Wellington 6140, fax 04 495 3076 or
counselling@victimsupport.org.nz

• I will only charge Victim Support the agreed fee and will not make any additional charges to the client, unless there is agreement between all parties prior to commencing counselling.

• I will not exceed the approved number of sessions available to clients referred to me. (If you believe more sessions are required this will be considered on a case by case basis, dependent on the funding criteria and the circumstances of the client. A request for more sessions should be sent to the VAS Administrator at counselling@victimsupport.org.nz)

• I understand I will not be paid for any sessions that are not approved by Victim Support.

• I will be willing to liaise with Victim Support employees on matters related to the
administration of the Victim Financial Assistance Scheme.
I agree to the above terms and conditions*

YesNo
Should be Empty:

Counsellor Application Form

Consulting Address

Documentation you need to include with this application:

A completed VAS Counsellor Referee Check Form from your current or most recent clinical supervisor.

Police vetting

Photo ID

Terms and conditions