Fillable Statutory Registration Application Form 2020 V2.0 D9364 Open Arms Outreach Program Statutory Registration Application

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Statutory Registration Application Form 2020 V2.0 D9364 Open Arms Outreach Program Statutory Registration Application

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Country of origin: AUSTRALIA
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Open Arms Outreach Program
Statutory Registration
Application
Open Arms – Veterans & Families Counselling is Australia’s leading provider of high quality mental health assessment and
clinical counselling services for Australian veterans and their families. Open Arms maintains an extensive network of external
service providers to increase the capacity and diversity of service provision.
To be eligible to provide outreach services, a provider must:
Two (2) years experience for Group Program Facilitators or Clinical Supervisors.
hold unconditional registration as a psychologist with the Australian Health Practitioner Regulation Agency (AHPRA); or
hold accreditation as a Mental Health Social Worker with the Australian Association of Social Workers (AASW); and
have a Medicare Australia provider number; and
have an Australian Business Number (ABN); and
hold, or be able to obtain, a Working with Children/Vulnerable People card or a positive assessment letter with respect to
their position; and
agree to maintain a specialist knowledge and understanding of veteran and military culture that enables delivery of a
specialised service to eligible Open Arms clients.
Desirable qualication
•
•
•
•
•
•
Please note:
•
Lodging an Application for Statutory Registration does not guarantee you will be registered as an Open Arms Outreach Program
Clinician.
Statutory Registration and induction into the Open Arms Outreach Program does not guarantee your services will be utilised.
Outreach Program Clinicians are matched to clients depending on the service needs of each area.
By applying for statutory registration with Open Arms as an Outreach Program Clinician you agree to comply with the
conditions set out in the Provider Notes which can be found at: https://www.openarms.gov.au/professionals/work-open-arms
•
•
I am applying to provide:
(Tick all that apply).
Group Program Facilitation (complete PARTS A, B, C, E, F & H)
Individual, Couples/Family Counselling (complete PARTS A, B, C, D, E & H)
Clinical Supervision (complete PARTS A, B, C, D, G & H)
Part A Applicant Details
2: Surname
3: Given name(s)
4: Briey explain how your skills
and experience relate to
improved functioning for
veterans and their families
Prof Dr Mr Mrs Ms Other
1: Title
Please attach a copy of your current resume plus relevant certications
and registration documents to your application.
To be completed by ALL applicants
D9364 0220 P1 of 7
IMPORTANT
5: Registered business name
9: Primary email contact
11: Medicare Provider Number
7: Australian Business Number (ABN)
10: Do you have Public Liability
insurance?
12: Do you have a practice address?
8: Primary mobile contact
Part B
POSTCODE
POSTCODE
Monday Monday
Tuesday Tuesday
Wednesday Wednesday
Thursday Thursday
Friday Friday
Saturday Saturday
Sunday Sunday
POSTCODE
– – –
6: Postal address
Practice name 1.
Practice manager name Practice manager name
Medicare Provider Number
Contact number for clients
Business Details
To be completed by ALL applicants
Only complete this section if you have a practice address
Practice hours
Practice hours
Practice address 1.
Wheelchair access?
Do you accept service animals?
Wheelchair access?
Do you accept service animals?
Practice address 2.
Practice name 2.
Medicare Provider Number
Contact number for clients
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Please complete details belowPlease go to Question 13
Yes
Yes
D9364 P2 of 7
13: Australian Health Practitioner
Regulation Agency (AHPRA)
Registration number
Are you an AHPRA certied Clinical Supervisor?
Do you hold clinical endorsement?
Are you an AASW registered Professional Supervisor?
14: Australian Association of Social
Workers (AASW) Registration
number
15: Registration or Card number
(if applicable)
Part C
Professional Details
To be completed by ALL applicants
AHPRA APPROVED PSYCHOLOGISTS
SOCIAL WORKERS (MENTAL HEALTH)
WORKING WITH CHILDREN/VULNERABLE
PEOPLE
Part D
Training and Experience
To be completed by Individual, Couples/Family Counsellors and Clinical Supervision applicants ONLY
Mark the corresponding box if you are
currently using or are experienced in
these trauma focussed interventions
and provide details of accredited
training and year of completion
SPECIAL INTEREST/EXPERTISE
We assume expertise in high prevalence
disorders – please let us know if you
have skills with other presentations
and when you last had training (e.g.
couple therapy, family therapy, child and
adolescent therapy, alcohol or other
drugs, family violence, trauma, eating
disorders, pain, sexual dysfunction etc.)
No
No
No
Intervention
Special interest /Expertise
Exposure therapy
for PTSD–Prolonged
imaginal exposure
Cognitive Processing
Therapy CPT for PTSD
EMDR
Other (please provide
details)
Training and year
Training and date completed
Yes
Yes
Yes
Yes
D9364 P3 of 7
Please provide a copy of your
registration
Please provide a copy of your
certication
Please provide evidence of
your endorsement
Please provide a copy of your
certication
Please provide a copy of your
registration
Please provide a copy of your
card
Part E
16: Please indicate which of the
following client presentations you
would feel competent working
with if referred:
17: Are there any particular
presenting issues or clients
that you prefer NOT to work
with?
18: Is there anything else you
would like us to know?
Anger
Memory Problems
Anxiety & Phobias
Military issues, Discharge/Adjustment
Assertiveness Training
Parenting
Bipolar Disorder
Post Deployment
Chronic Pain
Post–Traumatic Stress Disorder (PTSD)
Conict Resolution
Couples/Family Counselling
Depression
Post–Natal Depression
Domestic Violence
Relationships
Eating Disorders
Self–Esteem & Self Development
Family Relationships
Self–Harm
Financial
Sexual Difculties
Gambling
Group Treatment Programs
Sleep Disorders
LGBTIQ issues
Stress
Grief & Loss
Substance Abuse
Suicidality
Health and Wellness
Trauma Related Symptoms
Housing
Unemployment/Job Seeking
Impulsive Behaviours
Violence from others
Internet Pornography
Violence to others
Legal
Work Stress
Life transition and adjustment issues
Workplace Bullying
No
No
Yes
Yes
Please give details
Please give details
Referral Preferences
To be completed by Individual, Couples/Family Counsellors and Group Program Facilitators ONLY
D9364 P4 of 7
Part F
19: Please provide brief details
regarding your group facilitation
experience with references to any
relevant areas of intervention.
Include any specialist group
facilitation training undertaken
and the year of completion.
20: Briey explain your demonstrated
skills and experience in preparing
group facilitation plans and
writing group participant reports.
Group Program Facilitation
To be completed by Group Program Facilitation applicants ONLY
A minimum of two years experience providing group treatment programs is desirable.
21: Please provide the names and
details of two (2) professional
referees who are not DVA/
Open Arms employees, who
may be contacted to verify your
experience.
1. Referee’s name and organisation
2. Referee’s name and organisation
Phone
Phone
Relationship and description of services provided
Relationship and description of services provided
[ ]
[ ]
Email
Email
D9364 P5 of 7
Part G
Clinical Supervision
To be completed by Clinical Supervision applicants ONLY
A minimum two years of experience providing clinical supervision is desirable.
24: Please provide the names and
details of two (2) professional
referees who are not DVA
employees, who may be contacted
to verify your experience.
D9364 P6 of 7
22: Please provide brief details
regarding your supervisory
experience with references to any
relevant areas of intervention.
Include any specialist
supervisory training undertaken
and the year of completion.
23: Briey explain your demonstrated
skills and experience in preparing
supervisory plans and writing
clinical supervisory reports.
1. Referee’s name and organisation
2. Referee’s name and organisation
Phone
Phone
Relationship and description of services provided
Relationship and description of services provided
[ ]
[ ]
Email
Email
Part G
Clinical Supervision
cont..
25: Identify the Open Arms
centres where you are able to
provide supervision.
(Please tick relevant boxes)
Part H
Declaration
I conrm that the information given in this form is true and correct
I conrm I have attached my current resume and copies of relevant qualications
and registrations
/ /
27: Date
To be completed by ALL applicants
Please submit this form to openarms.opcmanagement@dva.gov.au by clicking on the email button below.
Individual face to
face supervision
Open Arms Centres
Adelaide
Albury/Wodonga
Brisbane
Canberra
Darwin
Hobart
Launceston
Lismore
Maroochydore
Melbourne
Newcastle
Perth
Southport
Sydney
Townsville
Cairns
Remote supervision – via
video conference, skype or
telephone
26: I conrm:
I have read and agree to the terms and conditions as laid out in the Provider
Notes.
I agree to maintain a specialist knowledge and understanding of veteran and
military culture to enable me to deliver services to Open Arms clients.
D9364 P7 of 7
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Statutory Registration Application Form 2020 V2.0 D9364 Open Arms Outreach Program Statutory Registration Application

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Completed 3 July 2020

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