National Register Renewal Listing Form
July 2012 – June 2013
SECTION 1: YOUR DETAILS
Your personal details will be treated as private and confidential
Family Name: Title:
PACFA Register No:
Name of PACFA 2. * Member Association/s:
* Please enclose proof of current membership of one or more Member Associations
All PACFA Registrants are listed on the PACFA website. Please specify any changes to your public
listing on the PACFA website:
Practice Address 1:
Practice Address 2:
Practice Address 3:
Professional Indemnity Insurance
Please attach a certificate of currency for your Professional Indemnity Insurance. Your Professional
Indemnity must cover the totality of your work as a Psychotherapist or Counsellor.
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.
SECTION 2: PROFESSIONAL SUPERVISION
Registrants are required to have completed 10 hours of clinical supervision from 1/7/2011 to 30/6/2012. Supervision – Supervision may, for the purpose of this application, take the form of individual or small group meetings (a maximum of six supervisees and a supervisor). It is not the same as administrative or management supervision, nor is it the same as psychotherapy or counselling of the supervisee. PACFA does not accept supervision in dual relationship situations.
Peer supervision – The 10 hours of supervision can be peer supervision only if practitioners have been listed as Clinical Registrants with PACFA or maintained full membership with their member association for at least 5 years. Peer supervision is a formal process where clinicians contract to provide collegial critiquing and enhancement of each other’s clinical work. Colleagues or peers work together for mutual benefit, rotating the roles of supervisor and supervisee. Peer supervision can be undertaken as a dyad or within a small group of no more than 6 members.
Please note: PACFA does not accept supervision by relatives or partners.
Supervision was: Individual Session Duration (minutes):
Peer Session Duration (minutes):
Group Session Duration (minutes):
(maximum of 6 people)
Number in Group:
This report relates to / /2011 to / /2012 the period from:
Total Supervision Total Client Contact
hours in this period: hours in this period:
Supervisor’s Registrant’s signature:
If you have more than one supervisor please photocopy this page.
SECTION 3: PROFESSIONAL DEVELOPMENT
Please list and attach 15 hours of professional development accrued between 1/7/2011 and 30/6/2012. Professional development supports practitioners to keep up to date with new developments in practice. Professional development must be relevant to ongoing clinical practice and to the core competencies of psychotherapy and counselling practice.
Attach a copy of verifying documentation relating to each PD course undertaken.
Course Name and type of Activity Course Provider Date Hours
Total PD Hours
SECTION 4: MENTAL HEALTH PRACTITIONER LISTING
Currently PACFA Mental Health Practitioners are required to undertake additional supervision and professional development each year relating to their mental health practice:
; Mental Health Practitioners will need to demonstrate that they have completed 10 hours of
Professional Development relevant to maintaining their mental health competencies annually.
; Mental Health Practitioners will need to demonstrate that they have undertaken 10 hours of
supervision in relation to their mental health practice. Peer supervision will not be accepted.
; Mental Health Practitioners will need to maintain their Clinical listing and meet Register renewal
requirements in addition to the renewal requirements for Mental Health Practitioners. In the renewal period 1/7/2012 to 31/6/2013, Mental Health Practitioners are not required to meet these additional requirements as they have been listed for less than a year.
Mental Health Practitioner Renewal Please tick
If you are a Mental Health Practitioner, please tick here if you wish to automatically renew
your Mental Health Practitioner Listing
If you have a Medicare Provider Number, please tick here and provide your number
Medicare Provider Number:
SECTION 5: REGISTRANT DECLARATION
I (print name) confirm that: Please tick:
; I have professional indemnity insurance cover in place and agree to maintain
continuous cover for the duration of my registration.
; I am a current member of my member association(s).
; I agree to be bound by the Code of Ethics and undertake to comply at all times with
the procedures specified therein.
; I have never been de-registered or removed from a professional register
for ethical reasons
; I have not had any proven complaints of professional misconduct, nor performance
or disciplinary actions issued against me or my practice in the last 12 months
; If you have had any proven complaints or performance/disciplinary action issued against you in the last 12 months, please attach documentation outlining the nature
and outcome of the complaint.
; The information I have provided on this form is true and correct.
SECTION 6: DOCUMENTARY EVIDENCE
I have provided PACFA with the following documentation:
; A copy of my Professional Indemnity Insurance certificate of currency
; A letter from my employer stating that I am covered under my employer’s
Professional Indemnity Insurance
; A copy of my current Member Association/s membership certificate or a copy
of my current renewal receipt(s)
; My completed Supervision documentation verified by my supervisor(s)
; My completed log of professional development together with evidence for
each Professional Development activity undertaken
thPlease return your form to the PACFA office no later than 30 June 2012
Please return to:
290 Park Street, North Fitzroy VIC 3068