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

Counsellor
Supervisor
Drug & Alcohol Assessor
Careers Practitioner
Psychologist

First Name

Last Name

Home Phone (optional)

Work Phone

Mobile Phone

Work Address (primary)

Your email address?

Suburb

City

Postcode

Please provide your GST number if registered

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 Number:

Date first Registered

Years Counselling Post Grad

Please confirm that you are willing to submit to a NZ Police vetting check?

Yes
No

Can you respond to clients by phone in 24hrs

Yes
No

Can see see urgent referrals if required

Yes
No

Areas of Speciality

Experience with Addictions

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.)

Trauma

Supervision

Coaching

Mediation

Careers

Ethnicity

Details of Hapu and Iwi

Are you fluent in any other languages (Please list)

Dispute Resolution

Yes
No

Have you had a complaint against you?

Yes
No

If so, what action was taken?

Indemnity insurance

Yes
No

Name of Insurer

Supervision:

Yes
No

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?

Yes
No

If so please give details:

Other comments:

How did you find out about us