ACC2467 SUPERVISOR REPORT FOR COUNSELLOR REGISTRATION COMPLETE THIS FORM

1. Counsellor registration details

Full name of the person who is applying for counsellor registration:      

Please tick the area(s) of counselling the counsellor you are supervising is applying for registration in:

sexual abuse counselling

physical injury counselling

2. Your details

Your title:      

Your ACC provider number, if you have one:      

Your full name:      

The name of the practice you work from:      

Your contact number:      

Your mobile number:      

Your email address:      

Your postal address:      

Your physical address:      

3. Your employment and membership details

What is your occupation?      

What organisation(s) are you employed by or affiliated to at the moment?      

How many years counselling experience do you have?      

Please tick the boxes in the table below to show which professional body(s) you are a member of and add the date you got your membership.

Professional body

Tick if a member

Membership date

Royal Australian and New Zealand College of Psychiatrists

     

The New Zealand Association of Child and Adolescent Psychotherapists (Incorporated)

     

New Zealand Association of Psychotherapists Incorporated

     

The New Zealand College of Clinical Psychologists Incorporated

     

New Zealand Psychological Society Incorporated

     

New Zealand Association of Counsellors Incorporated/ Te Roopu Kaiwhiriwhiri o Aotearoa

     

Aotearoa New Zealand Association of Social Workers Incorporated / Tangata Whenua Takawaenga o Aotearoa

     

New Zealand Christian Counsellors Association

     

Addiction Practitioners’ Association of Aotearoa-New Zealand

     

Australian and New Zealand Arts Therapy Association

     

4. Your supervisory details

Please tell us about any specialist training you’ve had in the area of counselling that the counsellor you’re supervising is applying for registration in.

Training date(s)

Training type eg workshop, seminar, conference

Specific topic covered in training

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

Please tell us about any specialist experience you’ve had in the area of counselling that the counsellor you’re supervising is applying for registration in.

Please explain your understanding of whānau and how you apply this understanding when counselling Māori clients.

Please explain the networks you have with local Māori health, social and educational organisations.

Please explain how you are supervised, including details about how often you are supervised and how long the supervised sessions are.

5. Your assessment details

Do you think the person you supervise has the empathy, genuineness, integrity, positive attitude, non-judgemental approach and assertiveness needed to provide sexual abuse counselling to our clients?

Yes

No

If no, please explain why:

Do you think that the person you supervise has the professional skills to provide sexual abuse counselling to our clients?

Yes

No

If no, please explain why:

If you weren’t their supervisor, would you refer your friends or family to them for sexual abuse counselling?

Yes

No

If no, please explain why:

Please explain how the person you supervise shows their concern for the safety and/or stability of their clients and what they do about it:

Please explain how the person you’re supervising deals with disturbing material

Many clients have complex needs which are unable to be met by ACC sexual abuse counselling alone. Please explain how the person you’re supervising identifies and manages additional issues.

6. Attachment details

Please return this report to us with the following documents after signing and dating the declaration.

I have attached:

a copy of my annual practising certificate (APC) or certificate of competency

a copy of my full and current membership to a professional body for counselling

my completed New Zealand Police Vetting Service Request and Consent form.

7. Declaration and signature

I confirm that:

• I have a full and current membership of a professional body for counselling

• I have at least three years counselling experience

• I have not, within the past five years:

  • had my employment or affiliation terminated for disciplinary reasons

  • been convicted of an offence under sections 124 to 210 of the Crimes Act 1961 or a similar offence in another jurisdiction

  • been detained in a penal institution

  • been disbarred for proven disciplinary reasons from membership of an organisation or body

  • had any sexual, parental or filial relationship with the counsellor that I supervised and who is the subject of this report.

Signature:

Date: