PO Box 1040
CIVIC SQUARE
ACT 2608
T: 0402 047 823
F: 02 6262 9993
E: office@capacar.org.au
W: www.capacar.org.au
ABN: 50 615 178 347
A member association of the Psychotherapy and Counselling
Federation of Australia Inc. (PACFA)
CAPACAR INC. Membership RENEWAL FORM/ INVOICE
1st July 2012 – 30th June 2013
1. Personal Details
Please add your details to update our membership system – please PRINT Clearly.
Member number
Title
First Name
Middle Initial
Surname
Company/employing organisation
Postal address
Suburb
State
Home Phone
Work Phone
Email
Postcode
Mobile
Fax
2. Membership category and renewal fee – please read appendix for criteria
Clinical Member $250.00 (includes $159.80 PACFA levy)
Associate $175.00
Student $85.00
Affiliated Member $100.00 (See Separate membership form)
3. Supervision - please see CAPACAR log attached.
Clinical Members need to provide evidence of 10 hours (minimum) of appropriate supervision, relating to clinical
practice over the past 12 months. Please use CAPACAR’s log provided or letters from supervisors may be
tendered as evidence.
Do you offer professional supervision?
Supervision qualifications (if any)
Please return this completed form by: email to office@capacar.org.au; post to CAPACAR Inc Membership,
PO Box 1040, CIVIC SQUARE, ACT 2608.
Payments can be made by EFT, cheque, money order.
1
PO Box 1040
CIVIC SQUARE
ACT 2608
T: 0402 047 823
F: 02 6262 9993
E: office@capacar.org.au
W: www.capacar.org.au
ABN: 50 615 178 347
A member association of the Psychotherapy and Counselling
Federation of Australia Inc. (PACFA)
4. Professional Development From July 2012 all Associate and Clinical Members will be asked to provide
evidence of 15 hours (minimum) professional development, over the previous 12 months.
5. Indemnity Insurance
a). Applicants for renewal of Clinical and Associate Membership need to be covered by Counsellor’s or
Psychotherapist’s Professional Indemnity Insurance - either privately or through an employer.
b). Evidence - in the form of a photocopy of the Certificate of Currency or Policy Schedule- to be attached to the
Membership
renewal form
c). For those practitioners who are employed, please provide evidence of your employer’s Indemnity Insurance
cover.
6. Criminal charges or Complaints
Since your last renewal have you had criminal charges or complaints against you in relation to your work as a
counsellor? YES / NO (If YES please provide details on a separate sheet of paper).
7. Dismissed from another association
Since your last renewal have you been dismissed from another association YES / NO (If YES please provide
details on a separate sheet of paper).
* Please note that a criminal record, a complaint or a dismissal from another association do not automatically
exclude membership. However, an application may require the approval of the CAPACAR Executive Committee.
8. Certificate Disclaimer
Membership certificates will be sent to members via email.
9. Declaration – please read carefully before signing
The information on this form is true and correct to the best of my knowledge; I am prepared for any information
given on this form and accompanying documentation to be verified; and I have read and agree to abide by the
CAPACAR Inc’s Code of Ethics.
Signature
Date
Please return this completed form by: email to office@capacar.org.au; post to CAPACAR Inc Membership,
PO Box 1040, CIVIC SQUARE, ACT 2608.
Payments can be made by EFT, cheque, money order.
2
A member association of the Psychotherapy and Counselling
Federation of Australia Inc. (PACFA)
PO Box 1040
CIVIC SQUARE
ACT 2608
T: 0402 047 823
F: 02 6262 9993
E: office@capacar.org.au
W: www.capacar.org.au
ABN: 50 615 178 347
The contents of this application, when completed, are CONFIDENTIAL, and are to be viewed only by those appointed
by the CAPACAR Inc. to conduct the application assessment and surrounding processes.
Membership inquiries should be directed to the Membership Secretary at
capacarmembership@gmail.com
Payment method – please tick one
Cheque
Money order
EFT (BSB: 112-908 Account no: 438 462 859, Reference: include
Surname and membership number, note EFT payment receipt number here..…….….)
OFFICE USE Receipt number
Date recorded on database……………………..
GST does not apply to membership fees
Membership categories
Clinical Member – this category of membership is open to people who have:
a. Completed a tertiary or equivalent course in Counselling or Psychotherapy of at least 200 contact hours
extending over 2 years (e.g. a Graduate Diploma course) with at least half of the training course being
experiential. The course must be VETAB or ITAB accredited and also meet the minimum standards of
PACFA.
b. Have practised as a Counsellor or Psychotherapist and received at least 50 hours of appropriate
supervision linked to 200 hours client contact
(1) Postgraduate Equivalent
Relevant Degree + Specialist Training in Psychotherapy or Counselling (2 years - 200 hours of training
plus 50 hours of supervision linked to 200 client contact hours). Note: evidence of 200 client contact
hours apply to applicants from 2011 onwards.
(2) Undergraduate Equivalent
3 years Training in Psychotherapy or Counselling (3 years - 350 hours of training plus 50 hours of
supervision linked to 200 hours of client contact hours).
(3) Recognition of Prior Learning
Where an applicant's professional training and formation does not fit the above, but is based on
extensive training, practice and supervision over several years, it may be possible to gain Clinical
Membership based on recognition of this prior learning (RPL).
These criteria comply with PACFA’s minimum requirements for membership of a PACFA Member Association.
People who are applying for this category of membership are asked to provide the following documents:
a)
b)
c)
d)
Completed membership form;
Certified copies of transcripts of results;
Outline of course syllabus;
Evidence of experience as a professional Counsellor or Psychotherapist (letters from employers may be
tendered as evidence);
e) Evidence of participation in appropriate supervision and number of hours completed (please use
CAPACAR’s log provided or letters from supervisors may be tendered as evidence).
f) Evidence of participation in continuing education; and
h) Evidence of Current Professional Indemnity Insurance.
Please return this completed form by: email to office@capacar.org.au; post to CAPACAR Inc Membership,
PO Box 1040, CIVIC SQUARE, ACT 2608.
Payments can be made by EFT, cheque, money order.
3
A member association of the Psychotherapy and Counselling
Federation of Australia Inc. (PACFA)
PO Box 1040
CIVIC SQUARE
ACT 2608
T: 0402 047 823
F: 02 6262 9993
E: office@capacar.org.au
W: www.capacar.org.au
ABN: 50 615 178 347
PLUS
Payment of $250, which includes a levy ($159.80) that will be paid to PACFA on your behalf.
Associate – this category of membership is open to people who have completed educational requirements and are in the
process of completing the number of supervision and client contact hours post training required for Clinical Membership.
Please include payment of $175.00, with your completed application form.
a)
b)
c)
c)
Completed membership form;
Certified copies of transcripts of results;
Evidence of participation in continuing education; and
Evidence of Current Professional Indemnity Insurance (if working as a counselling)
Student member – this category of membership is open to people who are currently studying to become counsellors or
psychotherapists. Please include payment of $85.00, with your completed application form and provide us with the details
of your training course.
Affiliated member – represents a truly worthwhile investment in your career and professional development. This
category of membership is available for: people who are not presently engaged in practicing counselling and/or
psychotherapy but who are still interested in the field; people who teach in counselling and/or psychotherapy courses; or
those who work in occupations which involve the use of counselling skills and who have demonstrated knowledge and
interest in the counselling aspects of their job. Affiliate members are bound by CAPACAR's Constituation and Code of
Ethics."
Please complete separate Affiliated Renewal Membership form, and include payment of $100.00.
Leave of Absence – this category of membership is open to members wanting for whatever reason, to take time off from
their practice as a Counsellor or Psychotherapist. Leave of Absence is granted at the discretion of the CAPACAR
Executive for a maximum of 12 months.
Please complete separate Leave of Absence form and include payment of $20.00.
PACFA Register Application- CAPACAR is a Member Association of PACFA. If you are a CAPACAR Clinical
member and wish to be listed on any of the PACFA registers (Main register, Supervision register, Mental Health Register) you
are required to complete the appropriate PACFA Application form. When completed please forward all documents to
CAPACAR, with PACFA’s Fee’s plus a payment of $50.00 made out to CAPACAR, this $50.00 administration charge is nonrefundable.
PACFA Main Register $110 plus GST = $121.
PACFA Accredited Supervisor Application $80 plus GST +$88.
Register Listing re-activation Application $60 plus GST = $66 within 12 months of lapse of registration.
Eligible applications will be forwarded to PACFA.
Forms can be downloaded from the PACFA Website.
Please return this completed form by: email to office@capacar.org.au; post to CAPACAR Inc Membership,
PO Box 1040, CIVIC SQUARE, ACT 2608.
Payments can be made by EFT, cheque, money order.
4
PO Box 1040
CIVIC SQUARE
ACT 2608
T: 0402 047 823
F: 02 6262 9993
E: office@capacar.org.au
W: www.capacar.org.au
ABN: 50 615 178 347
A member association of the Psychotherapy and Counselling
Federation of Australia Inc. (PACFA)
CAPACAR Clinical Supervision Log
Name of Supervisee
Phone/email:
Date
Supervision
hours
Name of Supervisor
Phone/email:
Client hours for Supervisors signature
this period
I confirm the contents of this form are a true and accurate record.
Please return this completed form by: email to office@capacar.org.au; post to CAPACAR Inc Membership,
PO Box 1040, CIVIC SQUARE, ACT 2608.
Payments can be made by EFT, cheque, money order.
5
A member association of the Psychotherapy and Counselling
Federation of Australia Inc. (PACFA)
PO Box 1040
CIVIC SQUARE
ACT 2608
T: 0402 047 823
F: 02 6262 9993
E: office@capacar.org.au
W: www.capacar.org.au
ABN: 50 615 178 347
Signed __________________________________________ Date: ____________________
CAPACAR [ ] Clinical member [ ] Associate member [tick one]
Please return this completed form by: email to office@capacar.org.au; post to CAPACAR Inc Membership,
PO Box 1040, CIVIC SQUARE, ACT 2608.
Payments can be made by EFT, cheque, money order.
6