Tena Koe
Thank you for taking the time to complete this form – which is a required part of our application process.
All information that you provide is strictly confidential to Adventure Development and will not be
discussed outside the organisation without your consent.
Please attach a cover letter, a curriculum vitae (CV) and a current practising certificate or registration
certificate.
Please send the completed application to:
[person receiving the application]
Adventure Development Ltd
[address of office]
Or:
Email to:
[email address for person receiving the application]
If you have any further enquiries, please contact [person fielding enquiries and phone number]
Please assist us in improving out recruitment process by telling us where you saw this position
advertised:
Position applied for: CLINICIAN
Your full name:
TEOFILO O. PALSIMON JR.MA Psy, RPm, ICAP II
Previous names:___________________________________________________________________
Your current address:
LITTLE BAGUIO II, BRGY. IBABANG DUPAY, LUCENA CITY, PHILIPPINES
Daytime phone number: Mobile: Email:
_______________________ +639323141994 topj.psych@gmail.com
Residency status
Are you a permanent resident of New Zealand? Yes o No o
If no, (a) Do you have a work permit? Yes o No o
(b) If you do not have a work permit, when do you envisage obtaining one? I HAVE A
RELATIVE RESIDING IN NEW ZEALAND. I OUGHT TO OBTAIN A WORK PERMIT WHEN I SECURE A JOB
POSITION
(c) Are there any restrictions affecting your employment, for example to do with your
residency or visa? Yes o
No o
Health
This question is to ensure the environment you may be working in does not aggravate any health
problems you may have.
Have you had any injury or medical condition caused by gradual process, or disease, or infection or other
means (for example, hearing loss, sensitivity to chemicals or repetitive strain injuries), which the tasks
of this job may aggravate? Yes o No þ
If yes, please give details
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Do you suffer from any injury, disease, infection or other medical condition that may affect your work
performance or regular attendance? Yes o No þ
If yes, please explain your condition:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Do you have or have you been exposed to any infectious diseases recently? (i.e. measles)
Yes o No þ
If yes, please list below:
__________________________________________________________________________________________
__________________________________________________________________________________________
Please advise us of your immunisation status by listing any current vaccinations and dates below (i.e.
MMR, influenza)
VACCINATION FOR DENGUE
Authority to practise
I confirm I have full registration with a NZ professional body Yes o No o
I confirm I have provisional registration with a NZ professional body Yes o No o
Please note professional registration
A copy of the appropriate certificate and registration must be attached to this application.
I AM AN INTERNATIONALLY CERTIFIED ADDICTION PRACTITIONER. I AM WILLING TO OBTAIN
CERTIFICATION IN NEW ZEALAND IF NECESSARY.
Previous employment
Provide details for the last 5 positions you have held
Position Employer Start date Finish date Reason for leaving
PSYCHOTHERAPIST GIYA 2020 PRESENT N/A
(Private BRAINSPOTTING
Practice/Clinic) CENTER AND
PSYCH SERVICES
PSYCHOLOGIST DOH-TRC MARCH 2016 PRESENT N/A
(Full-time)
PSYCHOMETRICIAN A-MAX PSYCH 2017 PRESENT N/A
SERVICES
(PART-TIME)
PSYCHOMETRICIAN THE ONE ALGON 2015 2016 CAREER GROWTH
PLACE
FOUNDATION INC.
Periods not in employment
Please explain any periods when you were not employed (i.e. training, travelling, parenting)
_________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Convictions
Have you ever been convicted of a criminal offence or been the subject of a professional disciplinary
inquiry? Yes o No þ
If yes, please give details:
__________________________________________________________________________________________
__________________________________________________________________________________________
Police check
I hereby give the organisation permission to seek a criminal conviction check /police check.
I confirm have filled in and attached the supplied forms Yes þ
Signature and date:
JULY 7, 2020
Ministry of Social Development check
I hereby give the organisation permission to seek a Ministry of Development check.
I confirm have filled in and attached the supplied forms Yes þ
Signature and date:
JULY 7, 2020
Motor vehicle licence
I have a valid licence Class A. Yes þ No ¨
The number is
D09-19-009514
Referees
Please list details of your referees. These should include at least two managers to whom you have
reported directly. By signing this form you give us permission to contact these people.
DR. MA. ALODIA CUENO MERCADO +639064537654
CLINICAL PSYCHOLOGIST alodiacuenomercado@yahoo.com
DR. MARCO ANTONIO R. RODAS +639325330761
CLINICAL PSYCHOLOGIST
Please note if you do not provide your current manager in the referees above, they will need to be
contacted before any written offer is made.
Declaration
I authorise Adventure Development Limited to obtain references to support this application and release
Adventure Development Limited and referees from any liability caused by giving and receiving this
information. I certify that all the information in this application is true and complete. Any false
statement may be sufficient cause for rejection or termination of employment if the application is
successful.
I understand that if my application is successful, I will be required to give more information about
myself and I also understand that any offer of employment may be subject to a satisfactory medical
clearance and pre-employment screening.
Signature and date:
JULY 7, 2020
Seven Real Skills
Mental health and addiction services in New Zealand are required to provide evidence that they are using
the seven Real Skills in developing their workforce and services.
In the table below, please document what experience you have had of each of these seven Real Skills.
For more information on the Real Skills please visit www.tepou.co.nz/letsgetreal.
Real Skill Definition What experience have you had of this
particular skill?
Working with service Every person working in a mental health MY CLINICAL PRACTICE IS STRONGLY
users and addiction treatment service utilises GROUNDED ON CLIENT-CENTERED
strategies to engage meaningfully and work APPROACH AND UNCERTAINTY PRINCIPLE. I
in partnership with service users, and DEAL WITH RESISTANCE IN MOTIVATIONAL
focuses on service users’ strengths to APPROACH RATHER THAN
support recovery. CONFRONTATIONAL; I AVOIND INFLICTING
ASSUMPTIONS AND HAVE ALL THAT I DO BE
BASED ON SCIENTIFIC KNOWLEDGE AND
FACT.
Working with Māori Every person working in a mental health I’VE BEEN RELIGIOUSLY INVOLVED IN
and addiction treatment service PROVISION OF MENTAL HEALTH SERVICES
contributes to whānau ora for Māori. ACROSS DIVERSED POPULATION (e.g.
ADULTS, CHILDREN, ELITE SOLDIERS,
PEOPLE DEPRIVED OF LIBERTY, VICTIMS OF
OPPRESSION AND DISASTERS, AND MOSTLY
INDIVIDUALS WITH DRUG DEPENDENCY).
Working with Every person working in a mental health I UNDERSTAND THAT ADDICTION IS ALSO A
families/whānau and addiction treatment service encourages FAMILY DISEASE. THE TREATMENT I
and supports families/whānau to PROVIDE ENSURES HOLISTIC APPROACH TO
participate in the recovery of service users, ADDRESS THE ISSUES AROUND WHICH THE
and ensures that families/whānau, FAMILY REVOLVE. SOME OF THE
including the children of service users, INTERVENTIONS THE CENTER OFFER ARE
have access to information, education and FAMILY DIALOGUE/COUNSELLING, FAMILY
support. SYSTEMS THERAPY, BEREAVEMENT AND
CRISIS INTERVENTIONS.
Working within Every person working in a mental health I’VE BEEN ENGAGED TO NUMEROUS
communities and addiction treatment service recognises COMMUNITY WORKS INCLUDING
that service users and their VOLUNTEERISM ON PROVISION OF CRISIS
families/whānau are part of a wider INTERVENTIONS AND PSYCHOEDUCATION
community. FOR INDIVIDUALS AFFLICTED WITH
NATURAL DISASTER, INTERPERSONAL
TRAUMA, AND ADDICTION
Challenging stigma Every person working in a mental health I CONTINUOSLY PROMOTE AND ADVOCATE
and discrimination and addiction treatment service uses AWARENESS THROUGH PSYCHOEDUCATION
strategies to challenge stigma and AND INFORMATION DISSEMINATION (e.g.
discrimination, and provides and promotes SEMINARS AND TRAININGS) IN THE
a valued place for service users. COMMUNITY. I FACILITATE TRAINING ON
SCREENING AND PROVISION OF BRIEF
INTERVENTION FOR COMMUNITY-BASED
REHABILITATION PROGRAMS.
Law, policy and Every person working in a mental health I UNDERWENT TRAINING ON PROFESSIONAL
practice and addiction treatment service ETHICS UNDER THE CURRICULUM OF AN
implements legislation, regulations, INTERNATIONAL ORGANIZATION FOR
standards, codes and policies relevant to SUBSTANCE ABUSE TREATMENT. ETHICAL
their role, in a way that supports service PRACTICE IS AT UTMOST PRIORITY IN OUR
users and their families/whānau. INSTITUTION.
Professional and Every person working in a mental health I HAVE SECURED CREDENTIALS AND
personal and addiction treatment service actively TRAININGS THAT PROMOTED MY
development reflects on their work and practice and COMPETENCE IN PROVIDING
works in ways that enhance the team to SCIENTIFICALLY-INFORMED AND EVIDENCE-
support the recovery of service users. BASED INTERVENTIONS.
