Title * Mr Mr Mrs Miss Ms Dr Prof
Full Names *
ID Number *
Gender * Female Female Male
Telephone (Office?Practice) Number *
Cell Phone or Mobile Number *
Alternative Contact Number *
Fax Number
Email Address *
Please select your preferred means of communication above telephone (Office?Practice) Number telephone (Office?Practice) Number Cell Phone or Mobile Number Fax Number Email Address
Will you be able to respond to referrals within a maximum of 4 working hours? Yes Yes No
Will you be able to submit your case notes after your sessions within 24 hours? Yes Yes No
Qualifications * MA Clinical Psychology MA Clinical Psychology MA Counselling Psychology B Soc Sc BSoc Sc Hons BA Welfare Sc BA Soc Sc
Year Obtained * 1995 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024
HPCSA/SACSSP Registration Number *
BHF Practice Number *
EAPA Registration * No No Yes
Total number of years in counselling experience, post-qualification? * 1 1 2 3 4 5 6 7 8 9 10+
Have you been subject to a disciplinary hearing with your professional board? * No No Yes
Please provide the necessary information in order for your application to proceed i.e. Date and outcome
Have you ever had clinical privileges suspended or withdrawn? * No No Yes
please provide the necessary information in order for your application to proceed i.e. Date and outcome
Are you in affiliation with any other EAP / EWP service providers? * No No Yes
Please indicate the names of the providers? * ICAS ICAS Momentum Workforce Healthcare Company Wellness EOH Health EAPA Kaelo Life Employee Health Solutions Reality Wellness Group
Please indicate your years of experience working with each of these service providers * 1 1 2 3 4 5 6 7 8 9 10+
Working knowledge of solution-focused therapy * No No Yes
Name of Qualification or formal training
Please indicate your years of experience working with solution-focused therapy: 0-1 Years 0-1 Years 1-3 Years 3-5 Years 5-10 Years 10+ Years
Name of Course
Please indicate other short-term treatment modalities utilised
Language Proficiency in counselling Arabic Arabic French Bantu Portuguese English Setswana Kirundi Swahili Criuolo Hansa Shaafi Islam Swahili Malagasu Lingala Kokongo Ishiluba Afar Somali Spanish Fang Bubi Creole Bilen Kunama Nara Tobedawi Saho Tigre Tigrinya Amharic Orominga Tigrigna Myene Bateke Bapounou/Eschira Portuguese Crioli Sesotho Zulu Khosa Malagasy Chichewa Hindi Urdu Hakka Bojpoori Berber dialects Bantu Langauges Afrikaans German Hausa Songhai Yoruba Ibo Kinyarwanda Wolof Serer Seselwa Mende Temne Krio Somali Italian Zulu Ndebele Sesotho sa Leboa Swati Xitsonga Setswana Tshivenda Swazi Ewe Mina Kabye Cotocoli Lugando Ateso Luo Shona
Speak Excellent Excellent Average Poor
Write Excellent Excellent Average Poor
Conduct Therapy Excellent Excellent Average Poor
Are you currently covered by an indemnity policy? Yes Yes No
If Yes, please indicate the name of the insurer?
Bank Name
Account Name
Account Number
Branch Name
Branch Code
Account Type (Cheque / Savings) Cheque Savings
SWIFT Code
Bank Physical Address
Country
Province
City
Suburb
Street Name
Additional address information
Postal Code
Practice Address
Country
Province
City
Suburb
Street Name
Additional address information
Postal Code
GPS Coordinates of Practice
Days Available at this Practice Monday Tuesday Wednesday Thursday Friday Saturday Sunday
From
To
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Is your practice easily accessible? Yes No
Does your practice offer parking that is easily available? Yes No
Is this parking safe and sufficient? Yes No
Is your practice easily accessible to people with physical handicaps? Yes No
Is your pratice wheelchair friendly? Yes No
Do you have a waiting / reception area? Yes No
Do you have a receptionist to answer calls daily during office hours? Yes No
Please provide us with their name and contact details:
Please explain how you manage incoming calls?
Practice Address
Country
Province
City
Suburb
Street Name
Additional address information
Postal Code
GPS Coordinates of Practice
Days Available at this Practice Monday Tuesday Wednesday Thursday Friday Saturday Sunday
From
To
From
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From
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From
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From
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From
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Is your practice easily accessible? Yes No
Does your practice offer parking that is easily available? Yes No
Is this parking safe and sufficient? Yes No
Is your practice easily accessible to people with physical handicaps? Yes No
Is your pratice wheelchair friendly? Yes No
Do you have a waiting / reception area? Yes No
Do you have a receptionist to answer calls daily during office hours? Yes No
Please provide us with their name and contact details:
Please explain how you manage incoming calls?
Practice Address
Country
Province
City
Suburb
Street Name
Additional address information
Postal Code
GPS Coordinates of Practice
Days Available at this Practice Monday Tuesday Wednesday Thursday Friday Saturday Sunday
From
To
From
To
From
To
From
To
From
To
From
To
From
To
Is your practice easily accessible? Yes No
Does your practice offer parking that is easily available? Yes No
Is this parking safe and sufficient? Yes No
Is your practice easily accessible to people with physical handicaps? Yes No
Is your pratice wheelchair friendly? Yes No
Do you have a waiting / reception area? Yes No
Do you have a receptionist to answer calls daily during office hours? Yes No
Please provide us with their name and contact details:
Please explain how you manage incoming calls?
Is your office entrance separate from the entrance to your residence? Yes No
Sound proof from other domestic disturbances? Yes No
Secured place for storage of clients information? Yes No
Separate toilet facilities? Yes No
Are pets securely locked away from client when then attend sessions? Yes No
Smart phone is capable of downloading the CaseLink application? Yes No
Agree to make use of the EAP online sytems and application to manage cases? Yes No
Are you computer literate? Yes No
Do you have internet access? Yes No
Do you have regular access to a reliable computer with internet connection? Yes No
Is it your personal computer? Yes No
Do you use a computer at an Internet Café? Yes No
Is it your employer’s computer? Yes No
Areas of Specialization / Interests Bereavement Depression Homicide Anxiety Eating disorders Stress Personal Development Spiritual Identity disorders Marital Counselling IMAGO Parental Guidance Emotional Abuse Sexual Abuse Physical Abuse Sexual &/ Reproductive Health Burnout Retrenchment / Restructuring Victimization General Trauma Gambling Technology Addiction Mindfulness Training Career Development Life Coaching Business, Executive and Leadership Coaching Family Life Coaching Health Coaching Relationship Coaching Grief Peer Group Pressure Depression Behavioural Trauma HIV/Aids Stress Technology Addiction Onsite Trauma Onsite Bereavement Retrenchment / Restructuring Divorce Child Support, Custody & Paternity Drawing up of Will Contractual & Consumer Protection Civil Rights Issue Personal Injury & Motor Vehicle Accident Property Related Criminal Law Internet & Social Media, ID Theft Social Security Financial and Tax Law Malpractice Personalised Exercise Programme Rehabilition Programme Ergonomic Programme Personalised Eating Programme Financial Coaching
Can you offer in-person counselling – Face-to-face counselling? Yes No
Can you offer in-person counselling – virtual/online counselling? Yes No
List the online counselling service that you use Whatsapp Video Skype Video Google Meet Microsoft Teams Zoom Other
Please Specify
Can you offer structured telephone counselling? Yes No
Can you offer structured email counselling? Yes No
Can you offer structured whatsapp counselling? Yes No
What types of interventions can you offer? Individual Couple Family Group
Do you offer counselling to the following clients? Adults Adolescents Children
Can you offer therapy to people with hearing disbilities? Yes No
Have you experience in counselling in the area of Gender Identity issues? Yes No
Are you willing to travel if required to do on-site trauma interventions? Yes No
Do you have your own transport?
Are you avaible 24/7 in case of emerngencies or onsite trauma incidents? Yes No
Do you have your own transport?
Are you willing to be a trainer or facilitator? Yes No
Previous years experience as trainer of facilitator 1 2 3 4 5 6 7 8 9 10+
Previous experience as trainer or facilitator – list courses you have presented Yes No
Do you have any training courses that you would like us to market to our clients? No Yes
Name of courses
Place to send a client in an emergency (Name of Institution)
Suicide and/or Crisis Interventions (Contact Person Name & Surname)
Doctors (GP’s; psychiatrists) – Contact Number/s
Places that assist in Substance Abuse both in-patient and out-patient facilities (Contact Email)
Places that assist in cases that involve Gender Based Violence and/or shelters
Places that assist in cases that involve HIV / Aids
Social Services – grants etc
Geriatric Facilities – old age homes
Support Groups
Adoption Services
Disaster Resources
Hospice & other Home Care services
Traditional Coming of Age Ceremonies
1. You receive a manager referral from the National Support Centre. You notice on the manager referral form that the manager has ticked substance abuse, absenteeism, and poor motivation. The manager consultation notes indicate that the client is often absent on Mondays and Fridays and has come to work smelling like alcohol. During your initial session the client indicates that he was admitted and treated for bipolar disorder 5 years ago but has not been compliant on treatment. The client indicates that although he does overindulge in alcohol in his personal time, there is no impact on work performance. The client goes on to say that he/ she would like bereavement counselling to address the sudden loss of his aunt last year. How would you manage this client? *
2. You receive a high risk self-referral from the National Support Centre. The case is flagged as high risk due to daily suicide ideation. In the initial session the client presents with moderate suicide risk and symptoms of depression, severe work performance impact, stress due to an on-going custody battle with her ex-husband, and financial challenges. How would you manage this client? *
Signed *