Private Therapists DatabaseApplication for Registration Form

Date:      

Private Therapist Name:

     

Practice Address:      

Practice Phone Number:

     

Email Address:      (Please note we will contact you via email from time to time to confirm accuracy of your details. Your email address will not be provided in referral information for clients)

Please complete the following questions regarding your practice. Please respond to all questions, as we are unable to process incomplete forms.

If your application for registration on the Private Therapists Database is successful, the information provided will be added to our Private Therapists Database, and will be provided to callers who request a referral.

Professional Qualifications and Experience

1. What are your professional qualifications? Please attach photocopies of relevant qualifications

     

     

2. What therapeutic framework(s) do you use?

     

3. How many years of counselling/psychotherapeutic experience do you have?

     

4. What experience have you had working with people who have experienced sexual violence?

     

Professional Supervision and Memberships

5. Do you receive regular clinical supervision?

     

6. Provide a referee who has had responsibility for supervising your clinical practice either currently or in the recent past.

Name:      

Telephone:      

7. Are you registered with any professional organisations? Please attach a photocopy of any membership/s.

     

     

Consultation Details

8. What is the average waiting time for an initial consultation?

1 week 1 month 6 months or more Other:      

9. How much do you charge per session?

     

10. Do you use a sliding scale of fees or have concessions? Yes No

11. Can you offer Medicare Rebate? Yes No

Please return this form, along with photocopies of relevant documents, such as your qualification(s) and membership(s) to Rape & Domestic Violence Services Australia via:

Post:Private Therapists DatabaseRape & Domestic Violence Services AustraliaPO Box 555,Drummoyne NSW 2047

Email:info@rape-dvservices.org.auPlease include “Private Therapists Database” in the subject line.

Thank you very much for taking the time to complete this form.