Quick Evaluation Form

Please take that if you exceed the 90 days provision for finalizing your ASCHP application your application will unfortunately be archived and you will have to reapply and forfeit any payments made.

Please fill in the form below. Please note that there is a non-refundable evaluation fee of R210.00 to be made out to the ASCHP when issuing this quick evaluation form before we can determine the relevant designation.

All documents must be certified and not be older than 3 months.

Please pay your evaluation fee into the following account:

Account name: ASCHP
Account number: 625 79188 204
Type of account: Business Cheque
Bank: FNB (First National Bank)
Branch: Kolonnade (25 10 37)
Reference: your name and surname

Personal Information:

Title: * Prof Dr Mr Mrs Miss

Name as per official South African ID or passport: *

Surname: *

Maiden Name (if applicable):

Nationality: * Please select one... Asian Countries Angola Australia Oceania Countries Botswana European Countries Lesotho Malawi Mauritius Mozambique Namibia North American Countries Other & rest of Oceania Rest of Africa South Africa SADC except SA Seychelles South / Central American Countries Swaziland Tanzania Unspecified Zaire Zambia Zimbabwe

Identity Number: *

Date of birth: *

Gender: * Please select one... Female Male

Marital Status:

Language Preference: *

Home Language: * Please select one... Afrikaans English isiNdebele Other South African Sign Language sePedi seSotho seTswana siSwati tshiVenda Unknown isiXhosa xiTsonga isiZulu

Where did you hear about us: *

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Are you a member of the CCSA?: * Please select one... Yes No

Are you a member of the NHA?: * Please select one... Yes No

CCSA Membership Number:

NHA Membership Number:

I am upgrading my membership:

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Contact Details:

Home:

Work:

Cell: *

Fax:

Email: *
Kindly ensure that the email address provided will remain active during the period of your membership with the ASCHP

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Relevant Documents:

If possible, please upload your documents in PDF format.

Certified copy of ID / Passport *

Transcript and/or proof of student registration *

Evaluation Fee Proof of Payment *

Signed POPIA Consent Form (click here to download) *

Proof of Residence *

Marriage Certificate

Work permit if non-South African (if applicable)

 

Click here to download the referent form. Kindly request 2 referents to each complete a form.

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Academic qualifications / informal / skills courses

Please fill in the details of all academic qualifications relevant to this application and attach certified copies plus academic transcripts.

Degree or Diploma Major Subjects Year Completed University / Institution Certified Document * click on the "+" icon to add another row

 

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Details of Counselling Experience

Place of work / institution Details of type of experience in relevant field Hours worked Proof of hours completed * Compulsory to upload proof of hours. If you do not have any hours, please submit a statement in your own words stating that you have no hours. click on the "+" icon to add another row

 

I give permission that my personal information can be verified *

I declare that there are no pending disciplinary/investigations cases against me *