e-cope directory€¦ · information about your professional skills and qualifications, and the...

How to register

Purpose

How the information is used

The e-COPE Directory Individual Practitioner Registration Form

Dr Nicole Highet

One of the greatest challenges for referring health professionals, women and their family members is being able to identify local services with expertise in perinatal mental health.

In response to this need, COPE, with support from the Commonwealth Government of Australia, has developed Australia’s first Perinatal Service Directory: The e-COPE Directory.

The e-COPE Directory serves to support consumers and health professionals in accessing timely support and treatment for perinatal mental health problems and associated risk factors.

To register your services you will need to complete and submit this survey to provide COPE with information about your professional skills and qualifications, and the nature and type of service(s) you

COPE Founder & Executive Director

COPE will assess the provided information pertaining to perinatal mental health expertise to identify whether you are suitably qualified to be listed on the e-COPE Directory. This ultimately serves to inform individuals and referring agencies about your service as a referral pathway to access timely support and treatment.

This registration has two sections:

Part A: Your professional profile – derives information about your professional qualifications, skills and experience in perinatal mental health. Here you will be required to upload supporting documentation to substantiate your qualifications and experience.

Part B: Details of the business entity(ies), site locations and the nature and types of services you are registered to provide.

We look forward to working with you to increase access to services for expectant and new parents across Australia.

e-COPE DirectoryIndividual Practitioner Registration

Which of the following Professional Bodies are you formally registered with? (Tick all that apply)

Royal Australian and New Zealand College of Psychiatrists (RANZCP)

Nursing and Midwifery Board of Australia

Australian Association of Social Workers (AASW)

Psychotherapy and Counselling Federation of Australia (PACFA)

Aboriginal and Torres Strait Islander Health Practice Board of Australia

Nurses Board of Australia (NBA)

Australian Psychological Society (APS)

Australian Clinical Psychology Association (ACPA)

Other - Write In (Required)

Do you provide your service in any languages other than English? Note: This pertains to languages for which you are confident to conduct a consultation.

Yes - Please specify No

Part A

Profile Overview

Please provide the following information about YOURSELF, as an individual practitioner, and the service you provide:Note: Information marked with an Asterix (*) will be visible on the public directory.

(Tick all that apply)

Prof / Assoc Prof / Dr / Mr / Mrs / Miss / Ms

Male / Female

Clinical Psychologist

Registered Psychologist

Social Worker

General Practitioner

Other (please specify)

Yes No

Occupational Therapist

Mental Health Nurse

Specialist Psychiatrist

Aboriginal Mental Health Worker

*Title:

*First name:

*Surname:

*Gender:

*Profession:

*APHRA Registration No:

Note: If you are a Social Worker and do not have an APHRA Registration number, please type ‘Not Applicable’.

Do you currently have any conditions as part of your APHRA registration?

Your Qualifications and Experience in Perinatal Mental HealthIn this section, we are asking about your personal qualification and expertise in perinatal mental health. Other than identifying specialist areas (*), all other information will only be used for internal verification purposes.

Perinatal Depression and Anxiety

Please indicate those conditions where you have specialist expertise in providing support/treatment for clients presenting with perinatal depression and/or anxiety.

For each area indicated, please detail specific training and/or skills that you have in this area.

Note: Please refer to the Perinatal Depression and Anxiety Matrix to inform your perceived level of competency.

Specialist Areas*(Tick all that apply)

Level of Qualification (Refer to Matrix)

Name of Specialist Training and/or Clinical Supervision Provider

Evidence of Qualification Uploaded(Tick)

Years of Experience

Antenatal depression

Intermediate

Advanced

Antenatal Anxiety

Intermediate

Advanced

Postnatal Depression

Intermediate

Advanced

Postnatal Anxiety

Intermediate

Advanced

In addition to the above, please detail your experience in providing treatment interventions for any of the following perinatal-related conditions or issues:

Specialist Areas*(Tick all that apply)

Name of Specialist training in this area and/or Clinical Supervision Provider

Evidence of Qualification Uploaded(Tick)

Years of Experience

Birth trauma

Grief and loss (due to miscarriage/ stillbirth)

Fear of birth

Counselling surrounding infertility

Bonding and attachment

Past trauma or abuse

Gender disappointment

Postpartum psychosis

Managing bipolar disorder in the perinatal period

Managing schizophrenia in the perinatal period

Managing borderline personality disorder in the perinatal period

Managing drug and alcohol misuse in the perinatal period

Same sex parenting

Do you provide treatment for any other specialist areas NOT listed above?

Do you have any special interest areas (outside of the above areas of expertise) that you would like displayed under your professional profile?

Are you registered to receive free updates on the latest developments in perinatal mental health from COPE?

If no:Please feel free to sign up to receive COPE updates via the provided link on completion of your registration (a link will be provided), or link to the Campaign Monitor data base using the contact details.

If Yes, please detail any other areas of (perinatal-related) training, experience and years of experience below.

Specialist training in this areaEvidence of Qualification Uploaded (Tick)

Years of Experience

1.

2.

3.

4.

Please indicate those theoretical approaches you currently use to inform your work: (Tick all that apply)

Acceptance and Commitment Therapy (ACT)

Compassion-Focussed Therapy (CFT)

Cognitive Behaviour Therapy (CBT)

Dialectical Behaviour Therapy (DBT)

Emotion-focussed Therapy (EFT)

Eye Movement Desensitisation and Reprocessing (EMDR)

Grief and Loss Counselling

Interpersonal Therapy (IPT)

Mindfulness-based Stress Reduction (MBST)

Mindfulness-based Cognitive Therapy (MBCT)

Non-directive Counselling

Psychodynamic Therapy

Schema Therapy/Cognitive Therapy


Yes (please specify)

No

Yes No

Name of legal entity (i.e. Business Name)

Name of Practice/Service*

ABN/ACN

Contact phone number*

Contact email address*

Company website*

One location

Two locations

Three locations

Four locations

Five locations

Part B

Details of the organisation(s) you are registering your services with

Please provide the following information regarding the Main Business Entity under which you provide your clinical service as an independent practitioner:Note: Information marked with an Asterix ( *) will be visible on the public directory.

Site/Location Details for Entity 1

How many sites or locations do you provide services across for this registered business /practice?

PO Box/ Locked bag details

Contact Details

PO Box/ Locked bag number:

Suburb:

Site phone number:

Site email address:

Website URL:

Display PO Box instead of physical address?

Are the contact details different to those for the main business entity?

If Yes:

Postcode:

Yes

Yes

No

No

Site Details

Physical Address*

*Site name:

Shop/Unit No:

Building Name:

Street Name:

Suburb:

*Description:

Postcode:

Note: This should be the business or trading name where the service operates

eg. private practice, medical centre

Location Details -Location 1

Are you registered with Medicare to provide mental health treatment (e.g. mental health treatment plan, psychological therapy, focussed psychological strategies, pregnancy support counselling) at this specific location?

Please provide your Medicare Provider Number for the relevant MBS item

If Yes:Please indicate the type of interventions you are registered to provide under Medicare at this location (Note: This will only be used for internal verification purposes)

Yes No

If Clinical Pyschologist in Part A - Profile Overview

If Registered Pyschologist in Part A - Profile Overview

MB Item Number MBS Provider Number for this location

Non-directive Pregnancy Support Counselling (MBS 81000)

Individual Psychological Therapy services provided by a clinical psychologist (Items 80000, 80005, 80010 and 80015)

Group Psychological Therapy services provided by a clinical psychologist (Item 80020)



Non-directive Pregnancy Support Counselling (MBS 81000)

Individual Focussed PsychologicalStrategies services provided by registered psychologist Items (Items 80100, 80105, 80110 and 80115)

Group Focussed Psychological Strategies services provided by a registered psychologist (Item 80120)


If Occupational Therapist in Part A - Profile Overview


Individual Focussed PsychologicalStrategies services provided by anoccupational therapist Items (Items 80125, 80130, 80135 and 80140)

Group Focussed Psychological Strategies services provided by an occupational therapist (Item 80145)


If Social Worker in Part A - Profile Overview

If Mental Health Nurse in Part A - Profile Overview


Non-directive Pregnancy SupportCounselling (MBS 81005)

Individual Focussed PsychologicalStrategies services provided by a social worker (Items 80150, 80155, 80160 and 80165)

Group Focussed Psychological Strategies services provided by a social worker (Item 80170)





If General Practitioner in Part A - Profile Overview



GP Mental Health Treatment Consultation (MBS items 2700, 2701, 2715 or 2717)

Review of a GP Mental Health Treatment Plan (MBS item 2712)

GP Mental Health Treatment Consultation (MBS item 2713)

GP Focussed Psychological Strategies (MBS 2721 to 2731)


If Psychiatrist in Part A - Profile Overview


Initial consultation for a new patient for an opinion and report or ongoing management (MBS item 291)


Please specify which of the following services apply to this specific location: (Tick all that apply)

Interpreter service available

Bulk bill service available

Bulk bill healthcare cardholder available

Referral required for all new patients/clients

Referral required for Bulk-billing only


Yes No

Yes No

Yes No

Yes No

Yes No

Please specify the mode(s) of delivery for services provided at this location: (Tick all that apply)

Face-to-face (individual)

Face-to-face (group)

Couples therapy

Family therapy

Telehealth (e.g. consulting via skype)

Home visiting service

After hours service available


Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Is this service currently listed with any of the following Directory Services:

Should COPE partner with other Australian health services directories in the future, would you like your details for this service to be shared with other directory services?

If no to (a) or (b):

a. The National Health Services Directory (NHSD)

b. Healthshare

c. Other (please specify)

Yes No

Yes No Undecided

Yes No

Is there any other information that you wish to include about your service at this location? (eg. GP referral required only for bulk-billing)

Do you also provide clinical services as an independent practitioner under another business entity?

Yes No

Other Business Entities

If yes, repeat Part B of the registration for each entity

COPE collects, stores, uses and discloses your personal information for the purpose of managing and verifying the information contained in the e-COPE Directory and complying with our legal obligations. If you do not provide your personal information, we may not be able to register you as an individual practitioner in the e-COPE Directory.

By submitting this information you acknowledge that the information will assessed by COPE to consider listing on the specialist e-COPE Directory, and that you consent to your details being listed on the e-COPE Directory as a publicly available record. If required, a representative from COPE may contact you to validate the information provided or to gather additional information where required. For more information, see our Privacy Statement or contact us at [email protected].

COPE may share relevant information with contractors that perform its services or store or dispose of its documents. We don’t disclose your information to anyone outside Australia.

For more information, see our Privacy Statement or contact us at [email protected].

I hereby consent that all information is true and current to the best of by knowledge.

I consent to this information being used for the purpose of review and inclusion in the e-COPE Directory.

I agree to remove amend or remove my professional profile or listing in accordance with any changes to my qualifications of professional registration.

Print name: Signature: Date: / /

Part C - Disclaimer

Thank you for your submision

To stay up to date with the latest resources and developments in perinatal mental health,ensure you are signed up to our health professional register www.cope.org.au/hpsignup

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