ICounsPsy

Institute of Counselling Psychology

Please tick which type of membership you are applying for: Required

Full Membership (Practitioner) Application

Full Membership (Academic) Application

Subscribership

Provisional Member (Practitioner) Application

Name Required

Qualifications- Please list all qualifications with dates of conferment Required

Affiliations- Please list affiliations apart from NZPsS

Registered Psychologist? Required

Yes

Current Employer

If employed, description of work and job title:

Part of the criteria for membership is that you have demonstrated expertise in, and /or interest in, counselling psychology. Please comment on this with regard to yourself:

Supervision

Name of Supervisor

Qualifications of Supervisor

Professional supervision details for the previous two years (full-time or equivalent): Supervisor and setting / Hours (eg, 1hr per wk) / Length of contact (eg, 4/17 to 6/19)

Applicants for full membership, please send the template for the supervisor’s report to your supervisor/s who will email it directly to national office. Download the template here.

If not in supervision please comment as to the reason and whether you plan to enter supervision at some stage:

Complaints Declaration

By submitting this form, I declare that to my knowledge there have been no complaints upheld or are currently being investigated about my practice which has resulted in formal investigation by any professional or statutory body.

If a complaint has been made and has, or is, being investigated please provide details:

I agree to be contacted if the committee of the Institute of Counselling Psychology requires any further information or evidence to support my application. Required

Yes