Registration of Interest- Wellbeing Network Survey

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* 1. First name, Last name (Please use your Legal name as per passport/ birth certificate)

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* 2. Date of birth

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* 3. Region

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* 4. Mobile phone number or Home phone (optional)

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* 5. Email address

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* 6. Address

Street address

Suburb

City

Post code

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* 7. Language Spoken

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* 8. Have you had a recent Police check completed

Yes, please email a copy to maricar.donila@explore.org.nz

Yes, Solora have an updated police check on my file

No, we will require this and follow up when we get in touch with you

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* 9. Do you have a current Annual Practising Certificate?

Yes, Solora have a copy of this on my file

If Yes, please indicate validity period

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* 10. What is your scope of practice?

Clinical scope

Counselling scope

Educational scope

General scope

Neuropsychologist scope

Intern

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* 11. Speciality areas

Māori

Pasifika

Anxiety

Depression

Psychotic disorders

Trauma

Perinatal mental health

Children and Youth

Parenting

Dementia

Substance abuse

Addiction

Brain Injury

Eating disorders

Grief and loss

Critical incident debriefing

Workplace wellbeing

Clinical supervision

Challenging behaviours

Disability

Neurodevelopment

Other (please specify)

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* 12. Therapy types

Acceptance and Commitment Therapy

Applied behaviour analysis

Cognitive analytic therapy

Cognitive behaviour therapy

Compassion focused therapy

Couples therapy

Dialectical behaviour therapy

Eye movement desensitisation and reprocessing

Group/family therapy

Mindfulness/MiCBT

Motivational interviewing

Narrative therapy

Neuro-linguistic programming

Parent-child therapy

Positive psychology

Rational emotive behaviour therapy

Schema therapy/mode therapy

Solution focused therapy

Strengths based therapy

Trauma informed therapy

Play therapy

Positive behaviour support

Other (please specify)

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* 13. Are you an ACC Registered practitioner?

Yes

Yes, Solora have this on my file

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* 14. What is your current availability?

Date available from

Hours per week

Detail preferences here

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* 15. Are you set up to work from home?

Yes

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* 16. Do you have access to technology and WiFi to enable videoconferencing capability?

Yes

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* 17. Are you confident/ have experience delivering therapy through video conferencing or phone?

Yes