Counsellor Application Form
PLEASE DETACH AND RETAIN THIS PAGE FOR YOUR INFORMATION IN THE FUTURE
Introduction:
Victim Support provides support services to victims of crime and other trauma throughout New
Zealand. As part of this support we offer some people free counselling delivered by an approved
professional counsellor.
In particular we offer free counselling services to:
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Family/whanau/close friends of victims of homicide (up to 30 sessions per person)
Family/whanau/close friends of victims killed by a criminal act (up to 30 sessions per person)
Victims of some serious crimes (up to 15 sessions per person)
People affected by natural disasters including drought and events in other countries that
have resulted in the loss of life (up to an agreed number of sessions).
Criteria for application to become a Victim Support Registered Counsellor
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Relevant qualifications to level 5/6 (Diploma) or above (Degree level) on the NZQA
Framework
At least three years’ experience in trauma and/or grief counselling or specialised training or
specialized training in trauma/grief counselling (for homicide/crime work)
At least two years’ experience in grief counselling, anxiety or depression work (for natural
disaster work)
Membership of a suitably recognised professional body in New Zealand e.g. NZAC, NZAP
Professional accreditation if available or applicable
Meeting professional standards in their own practice by receiving regular clinical supervision
from a qualified supervisor.
For more information about applying contact the General Manager Quality.
Counsellors, Psychotherapists and other health professionals who meet these criteria who wish to
be approved should complete the attached forms and return to:
Victim Support
General Manager Quality
Victim Support National Office
PO Box 3017
Wellington 6140
or email to [email protected]
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Information for Counsellors
One application form to be completed per counsellor. Organisations can only be approved in
consultation with the General Manager Quality.
Victim Assistance Schemes
Victim Support has four counselling schemes. You must be approved as a Victim Support Approved
Counsellor before you can be paid to provide counselling to approved victims under these schemes.
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Homicide Counselling (HC): Family/whanau/close friends of victims of homicide. 10 hours
are approved at a time with two extensions possible (max 30 hours per person)
Death by a Criminal Act Counselling (DCC): Family/whanau/close friends of victims killed by a
criminal act. 10 hours are approved at a time with two extensions possible (max 30 hours
per person)
Serious Crime Emergency (SCE): Victims of some serious crimes. Victims must be the primary
victim of a Serious Crime, have a Community Services Card, and have exhausted all other
avenues for counselling. 5 hours are approved at a time with two extensions possible (max
15 hours per person)
Civil Defence Emergency Management Counselling (CDEM): People affected by natural
disasters including drought and events in other countries that have resulted in the loss of life
(up to an agreed number of hours).
If you are contacted by a client who you think will meet the criteria for Victim Support funded
counselling please encourage them to contact Victim Support directly. You should not commence
counselling with this person and expect Victim Support to pay however unless you have received
confirmation from the Service Coordinator of the local office that the victim has been approved (see
Victim Referrals Process below).
From time to time Victim Support may also provide contact details of approved counsellors to
victims who do not qualify for Victim Support funded counselling, but who will pay for counselling
themselves. Victim Support cannot pay for counselling for these victims.
Victim Referral Process
If approved, Victim Support cannot guarantee that you will receive any referrals for Victim Support
funded counselling. This will depend on if there are victims of serious crime in your area who qualify
for funded counselling and if they select you as a counsellor.
When a victim meets the criteria for funded counselling an application is submitted for them by the
local Victim Support office and they are given a list of counsellors in their area to choose from. The
victim selects a counsellor based on the information taken from this application form e.g. your areas
of expertise, and the Volunteer Support Worker or Service Coordinator will also help guide them in
their selection. If approved, you may like to contact the Service Coordinator from your local office to
introduce yourself.
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If you are selected as the counsellor for a victim the Service Coordinator of the local office will
contact you and let you know;
 The name of the victim and the type of incident they were involved in
 The VAS Application Approval Number – this starts with VA and is followed by numbers. This
is unique to one individual and shows that an application has been made for them.
 The number of counselling hours that have been approved initially (5 or 10 depending on
the scheme)
 If the victim has already used up some of their hours by seeing another counsellor. The
hours with the other counsellor still count towards their overall hour allocation.
The victim will contact you to arrange the first appointment.
If you do not received this information then the victim’s application may not have been approved.
Please contact Victim Support local or National Office before commencing counselling to get this
information. No payment will be made for counselling that has not been approved.
Joint Sessions
Victims are approved individually for counselling, if a family sessions will be beneficial to the
individual then the session can be funded as part of that individual’s therapy, however if another
family member requires counselling for their own benefit then they need to be approved by Victim
Support before counselling begins. You will be given their unique approval number for the new
client when this has happened.
If a one hour joint session is held with two approved victims please record this as half an hour for
each victim.
No Shows/Late Cancellations
Please explain your cancellation policy to the victim at the first session. If they do not show or
cancel late and you would normally charge a client who was paying for themselves then you can
charge Victim Support for this. Please indicate on your invoice that it was a No Show/Late
Cancellation. Because we are charged for these they are deducted from the victim’s allocation of
sessions – if you charge half your normal rate then half an hour is deducted from the session
allocation.
Please notify the local Service Coordinator immediately if a victim has more than one No Show /
Late Cancellation.
Travel to Counselling Reimbursement
If a victim needs to travel more than 8km to attend counsellor they can get a Travel to Counselling
Reimbursement form from their local Victim Support Office. They will ask you to sign this form to
confirm they have attended the sessions before they submit the form to the local office for
reimbursement of travel costs.
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Invoicing
Please send a tax invoice to National Office each month, these can be posted or emailed to the
address shown below. Please send your invoice between the 20th and 30th of the month if you
require prompt payment on the 20th of the following month. Include a Verification of Payment form
with the session dates and return it with your invoice. If the charge is for a late cancellation/no show
please make this clear on the invoice.
Extension reports
Counselling is approved in blocks of 5 or 10 hours depending on the scheme. When you have
reached the number of approved sessions please send a report to National Office (there is no need
to copy in the local Service Coordinator). The report should be on letterhead or emailed from your
email address and briefly summarise attendance at sessions to date and the progress that has been
made. If you believe that more sessions are required please request these and briefly explain how
they will be used. You will be notified when more hours are approved. No payment will be made for
counselling that exceeds the number of sessions approved.
Fees
The approved counsellor will be paid the agreed rate for each approved session on invoice. The
agreed rate is the counsellor’s usual fee as indicated on the initial application form. The maximum
fee is $140 per hour plus GST if applicable. No additional charges may be made to the client.
Change of details
If your details change please contact National Office with your new details. If you wish to increase
your fee the new fee must be approved by National Office before you invoice a session at the new
rate.
Complaints
If we receive a complaint about you from a victim who has accessed your services via Victim Support
we will advise you of the nature of the complaint and ask you to discuss it with us. We will make an
internal decision about the complaint after hearing both sides of the issue and will advise you of the
outcome. If we feel the complaint is upheld we may decide to remove you from our approved
counsellor list. Our decision is final.
If the complaint is such that we believe you have breached the code of ethics of the professional
association you are affiliated with we will advise that association of the complaint and ask them to
also investigate it.
Contact Details
Victim Support National Office
PO Box 3017
Wellington 6140
Phone 04 470 7238
Fax 04 495 3076
Email [email protected]
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Counsellor Application for Victim
Assistance Schemes administered by
Victim Support
Name
Postal Address
Consulting Address
Phone
Email
Qualifications
Professional Memberships
Ethnicity/Iwi affiliation
Languages spoken
Areas of expertise/interest
Therapy Models you use:
(CBT, Spiritualist based,
hypnotherapy etc.)
Usual fee charged per session
$
Application for scheme (tick)
 Homicide and Death by a Criminal Act
 Other Serious Crime
 Natural Disaster
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(Please ensure that these sections are fully completed – referring to an attached CV will not be
accepted)
Recent education and relevant qualifications
Date attained
Qualification
Copy Attached
(tick)
Office Use
Summary of relevant work experience
Dates
Employer
Role
Name of two referees (including clinical supervisor)
Name
Contact phone and include email
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Terms and conditions
Submitting an application
Documentation included with application:
 A two page case study which anonymously describes a recent case you have dealt with,
describing your approach to the situation. Ideally this will be about grief and trauma, especially
relating to homicide, sudden death or suicide
 Evidence of qualifications attained (photocopies accepted)
 A copy of CV
 Evidence of current Membership of Approved Professional Body (photocopies of membership
and/or practicing certificate accepted)
 This completed application form
I agree that in submitting this application:
1. I have provided all the material asked for and that Victim Support may check my qualifications
and memberships with the relevant organisations.
2. Victim Support may contact my referees to discuss my application and my suitability for the
work I have sought approval for.
3. 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:
4. I will be readily available.
5.
I will continue to belong to a professional body, namely
*Please state the body you currently belong to
6. 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 [email protected]
7. I will only charge Victim Support the agreed fee and will not make any additional charges to the
client.
8. Tax Invoices, which will be accompanied by a ‘Verification of Payment’ form, will be submitted to
the National Office of Victim Support for payment.
9. I will not exceed the number of approved sessions, and I will provide reports requesting any
further sessions required, as outlined in Notes for Counsellors above.
10. I will be willing to liaise with the Victim Support Homicide Volunteer and/or Service Co-ordinator
on matters related to the administration of the scheme.
Name:
Signed:
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Office use:
 Meets work experience criteria
 Meets qualification criteria
 Meets membership criteria
Referee checks completed
 VAS Administrator advised
 Details entered into approved counsellor list on VIVA, hard copy filed
 Applicant advised and sent documentation
Approved By:
GM Quality
Date:
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