Clinician Application

Thank you for your enquiry about becoming a Vitae Clinician.

Vitae needs to gather sufficient information from you to allow us to assess your suitability  for the role.

Please complete the application form below. When you have completed your responses, please click on submit and make sure your survey is acknowledged on screen.

Please be assured the information collected is confidential.

Position Applying For*  
First Name *
Last Name*
Email Address *
Home Phone (optional)
Work Phone*
Mobile Phone*
Work Address (primary)*
Suburb *
City *
Postcode *
Availability for clients days and times*
Geographical Regions covered *
Work Address (secondary)
Suburb (secondary)
City (secondary)
Postcode (secondary)
Availability for clients days and times (secondary)
Geographical Regions covered (secondary)
Qualifications *
Annual practicing certificate expiration:*
Professional Memberships/Registration:*
Years Counselling Post Grad *
Please confirm that you are willing to submit to a NZ Police vetting check?* 
Can you respond to clients by phone in 24hrs * 
Can see see urgent referals if required * 
Areas of Speciality
Experience with Addicitons *
Experience with psychiatric diagnoses*
Experience with Critical Incident
Experience with sexuality, gender identity*
Training in Assessments*
Do you have qualifications in the following?(Please list.)
Details of Hapu and Iwi
Are you fluent in any other languages (Please list)
Dispute Resolution * 
Have you had a complaint against you?* 
If so, what action was taken?
GST Registered * 
Indemnity insurance* 
Name of Insurer*
How often?
Supervisors Name
Supervisors phone
Supervisors email
Referee 1 Name*
Referee 1 Phone:*
Referee 1 Phone 2:
Referee 1 Email:*
Referee 2 Name:*
Referee 2 Phone 1:*
Referee 2 Phone 2:
Referee 2 Email:*
Have you worked for other EAP providers or counselling services?* 
If so please give details:
Other comments:
How did you find out about us*
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