Renewal/Upgrade Status of Accredited Clinical Supervisor

renewal/upgrade status

If you have not held dapaanz registered practitioner status for at least two years*, then one of the following is required:

  • HPCA Registration number:
  • Social Work Board Registration number:
  • NZAC or NZCCA membership number:

Step 1 - complete online form

You will need: 

  • documentation of any Disclosure information that falls outside of the Clean Slate Legislation Act 2004 (uploadable)
  • documentation of registration/supervision training (uploadable)

Step 2 - supporting documents

You will need to:

Step 3 - return supporting documentation to dapaanz

You will need to:

  • send us your Assessment Report form 
  1. email: registrar@dapaanz.org.nz
  2. post: dapaanz, PO Box 25 283, Featherston Street, Wellington 6146

Step 4 - organise payment of fee

You will need to:

  • select your payment method ( in the Payment Details section of this form so we can email invoices etc.)
  • make/arrange payment of the fee for Upgrade Status for dapaanz Registered Practitioner $100.00 (incl GST) /  not registered with dapaanz (Registered with another registration body)  $210.00 (incl GST)

payment details

  • we prefer you pay by direct credit (ANZ Account: 06-0201-0631490-00). Please ensure you put your membership number and name in the reference box. If the fee is being paid by your Employer, please specify
  • if you need to pay by Cheque, please make payable to dapaanz and send to dapaanz via post (as above).

*Failure to return supporting documentation will lead to delays in processing your renewal/upgrade status

Renewal/Upgrade Status of Accredited Clinical Supervisor

Are you a machine? If not please enter nothing in here:

You have the right to ask for a copy of any personal information we hold about you, and to ask for it to be corrected if you think it is wrong. If you’d like a copy of your information, or want to have it corrected, please contact us at registrar@dapaanz.org.nz

Please select*
First Name(s)*
Surname*
Membership number:

If not a dapaanz registered practitioner for at least two years*, then:

  • HPCA Registration number:
  • Social Work Board Registration number:
  • NZAC or NZCCA membership number:
Other Registration/Membership Number
Preferred mailing address:*
Preferred mailing address (for certificates):*
Mobile e.g (64) (025) (555 5555)*
Telephone (work) e.g.(64) (04) (499 3083):

Due to work emails being blocked by some servers, we request that you supply us with a personal email address, so we can keep you up to date with any news and information

Private Email:*
Ethnic Identity (we collect this for reporting member statistics only)*

Criminal Conviction, Complaints and Disciplinary Disclosure

 

To reduce risk for clients, applicants are required to disclose any prior, current or pending complaints about professional practice and disciplinary actions, and convictions that fall outside of the Clean Slate Legislation (see below).

Please answer the following questions:

Have you been convicted of a criminal offence since your last application/renewal?*
Have there been any complaints about your professional practice upheld since your last application/renewal?*
Have you been subject to disciplinary action from your employer since your last application/renewal?*
If you have answered yes to any of the questions, provide details below
Upload Disclosure Document
Additional Disclosure Document
Additional Disclosure Document
  Checking this box confirms you have attached and disclosed all required information*

Note: Under the Clean Slate Act 2004 you don’t need to disclose your convictions if you meet all of the following conditions:

  • You have had no convictions within the last seven years
  • You have never been sentenced to a custodial sentence e.g. imprisonment, Corrective Training, or borstal
  • You have never been ordered by a Court following a criminal case to be detained in a hospital due to your mental condition, instead of being sentenced
  • You have not been convicted of a “specified offence” (e.g. sexual offending, offending against children, young people or the mentally impaired)
  • You have paid in full any fine, reparation, or costs ordered by the Court in a criminal case
  • You have never been indefinitely disqualified from driving.
Name of your Supervisor:*
Supervisors email:*
Number of years of clinical practice in addictions in the last 10 years*
Supervision training course attended*

Documentation of registration/supervision training

Upload Training Document
Upload Training Document

Supporting Document

Please note: If you do not have your supporting document  you must email it to, registrar@dapaanz.org.nz within two weeks of submitting this application

Assessment Report from Supervisor
I will email the Supervisor form seperately*

Accredited Clinical Supervisor Search

As a member of dapaanz, your name will go on the website in our searchable  Member Directory. The directory has a specific search for Practitioners looking for Accredited Clinical Supervisors. 

Do you want to be contacted by practitioners looking for Supervisors?*
If yes, you will be contactable by email *email addresses are never disclosed, an email can be sent to you via our website. It is up to you the Supervisor to be in contact with the individual you were contacted by
In signing and submitting this renewal form:*

Payment Details

Please select your fee type*
Please select your method of payment*

Notes

Please use the box below to note important details regarding your renewal/upgrade application, e.g. you plan to email copies of qualifications to us at a later date etc.

Notes:
  I hereby verify that all information on this form is true and correct to the best of my knowledge and agree to abide by the Code of Ethics*

Please be aware: Due to our internal processes we may take up to one month to process your application. You should expect to receive your certificate within this timeframe.