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Application Form

for Intern Listing on the PACFA National Register

Eligibility: Intern applicants must have completed a training program in counselling and psychotherapy that meets the PACFA Training Standards. The training must be completed over a minimum of 3 years for undergraduate training, or over a minimum of 2 years for postgraduate training. Applicants must also provide evidence of completing a minimum of 10 hours of supervision linked to 40 hours of client contact. These supervision and client contact hours must have taken place within the training program. 

PART 1: Personal Details

Your personal details will be treated as private and confidential

Family Name:

Title:

Given Names:

Postal Address:

Phone:

Email:

Member Association:

PART 2: Training

Please provide details of your counselling and psychotherapy training and evidence that the training meets PACFA’s training and supervised practice requirements for Intern Listing on the PACFA Register.

(1) Undergraduate Pathway

3 years Training in Psychotherapy or Counselling (A single 3 year – minimum 350 hour training course plus 10 hours of supervision linked to 40 hours of client contact).

 

(2) Postgraduate Pathway

Relevant Degree (as defined by the Applicant's Professional Association) plus specialist training in Psychotherapy or Counselling (A single 2 year – minimum 200 hour training course plus 10 hours of supervision linked to 40 hours of client contact).

Qualifications - Undergraduate pathway

Undergraduate degree in counselling or psychotherapy

Qualifications - Postgraduate pathway

Relevant undergraduate degree

Postgraduate qualification in counselling or psychotherapy


PART 3: Address Details for Publication

Please specify on this form the contact details you wish us to publish in the PACFA National Register of Psychotherapists and Counsellors website. All Register listings will be published.

Family Name

Title

First Name

Middle Name

Member Association

Qualifications

Other Professional Memberships

Practice Address

Street

City

State

Postcode

Email

Phone (work)

Phone (home)

Mobile phone

Website

The therapeutic approach you use in your practice: (Not currently for publication)

You practice as a:

 Psychotherapist

 Counsellor

Please tick the relevant boxes:

 Child Psychotherapy

 Cognitive Behaviour Therapy

 Couple Therapy

 Family Therapy

 Gestalt Therapy

 Hypnotherapy

 Psychoanalysis

 Psychodrama

 Other, please specify:

Please list any clinical issues you deal with in your practice: (Not currently for publication)

PART 4: Supervision

To be completed by the applicant’s supervisor:

Supervisor’s name:

Supervisor’s address:

Supervisor’s phone:

Email:

Supervisor’s Qualifications:

Supervision was:

 Individual

Session duration (minutes):

No of sessions:

 Group
(max. 6 people)

Session duration (minutes):

No of sessions:

Session duration (minutes):

Number in Group:

This report relates to the period:

to

The details reported on this page give an accurate description of our supervision arrangements.

Total supervision hours completed:

Supervisor’s signature:

Total supervision client contact hours completed:

Applicant’s signature:

* If you have had more than one supervisor, please make additional copies of this page.

PART 5: Professional Indemnity Insurance

Do you have current Professional Indemnity Insurance cover?

If Yes, please attach a certified copy of your certificate of currency. Alternatively, please provide written confirmation from your employer, or the agency where you are undertaking an internship, that you are covered by their professional indemnity insurance.

 Yes

 No

If No, you will not be listed on the PACFA Register until current insurance is obtained.

Practitioners who are not in private practice need to provide a letter from their employer stating that they are covered by their employer’s professional indemnity policy to practice as a therapist.

PART 6: Ethical Conduct

1. Are there any complaints of professional misconduct or any other disciplinary or performance action currently under investigation in relation to your work?

 Yes

 No

2. Are you aware of any formal complaints of professional misconduct having been made to any Professional Association against you at any time?

 Yes

 No

3. Have there been any proven complaints of professional misconduct or any other performance or disciplinary action made to or by any Professional Association against you at any time?

 Yes

 No

4. Have you ever been dismissed from a Professional organization because of reports of professional misconduct?

 Yes

 No

5. Do you have a criminal record? (Answering “Yes” will not necessarily exclude you from the Register)

 Yes

 No

6. Are you currently under investigation by State, Territory or Federal Police?

 Yes

 No

If you answered “Yes” to any of the above please provide more information and attach supporting documentation if necessary:

PART 8: Applicant’s Agreement

I have met the requirements for Registration on the PACFA National Register of Psychotherapists and Counsellors, and attached documentary evidence.

I agree to comply with continuing education requirements of the PACFA National Register of Psychotherapists and Counsellors.

I have read the Code of Ethics of PACFA and agree to be subject to the conditions of the PACFA Code of Ethics and to Complaints and Appeals Procedure of the PACFA Code.

I have read the Code of Ethics of my Member Association as audited by PACFA and I acknowledge that my remaining on the PACFA Register depends upon my adhering to its requirements.

I confirm that I am working towards accruing 200 client contact hours linked to 50 hours of clinical supervision for provisional listing on the PACFA Register. I understand that if this is not reached within two years, I will need to reapply for intern listing.

Date:      /     /20      Applicant’s Signature: ___________

PART 9: Checklist

I have attached with this application form:

A Certified copy of my certificate of currency for Professional Indemnity Insurance

OR

I am covered under the Professional Indemnity Insurance policy of my employer, or other agency where I am completing an internship, to practice as a therapist and have attached a letter from my employer stating this





Certified copies of my relevant academic transcript and award certificate



Certified Supervisor verification of supervision and client contact hours as required



I am forwarding this Application Form and accompanying documents, together with my MA Endorsement Form, to my Member Association for endorsement



Please send your application form and relevant documents with the $44 (including GST)
(non-refundable) application fee to your Member Association and they will forward the application to PACFA once it is endorsed



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