ABN 76 366 995 021
QCA is a constituent Member Association of the Psychotherapy and Counselling Federation of Australia Inc.
(PACFA)
Application for Renewal of QCA Membership
(Fellow/Clinical/Provisional/Associate)
July 2015 - June 2016
Contact details
Family Name
BLOCK CAPITALS PLEASE
Given Names
Postal Address
Post Code
Telephone
(w)
Email
(h)
(m)
Name of Employer or name of Private Practice
Position or Title
Current Membership Category (please tick)
Fee payable- includes GST (please tick)
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Fellow
Clinical
Provisional
Associate
Post Nominal: FQCA
Post Nom: MQCA (Clinical)
Post Nom: MQCA (Prov)
Post Nom: MQCA (Assoc)
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Fellow
Clinical
Provisional
Associate
$99
$348
$265
$220
(see Membership Criteria on QCA website)
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Please circle your response to the following requirements for continuation of Membership
Are you currently practising as a counsellor?
YES/NO
If ‘NO’ have you had approval of ‘Leave of Absence’
YES/NO
During the past 12 months have you:-
· A record of a minimum of 100 client contact hours? (you may include up to 75 hrs provision of supervision
if you are a QCA accredited supervisor)
YES/NO
· A record of a minimum of 10 hours counselling supervision linked to the above client contact hours?
YES/NO
Supervisor report confirming above attached
Current supervision contract attached
(TICK)
· A record of professional development (as defined in QCA Professional Development Policy)
equivalent to a minimum of 40 points?
· PD log attached
YES/NO
(TICK)
Are you currently covered by professional indemnity insurance for ALL areas of your counselling work?
YES/NO
Your membership cannot be renewed if any of the above practice requirements have not been met.
(see membership info on the website). Please contact the Registrar, registrarqca@optusnet.com.au , to discuss the matter if you
have been unable to fulfil any of the above requirements.
NOTE: You must keep evidence of all the above for a minimum of 3 years for audit purposes
During the last year have there been any substantiated formal complaints of professional misconduct in
relation to your work as a Counsellor/Supervisor/Trainer or are there any complaints currently under investigation?
YES/NO*
(If ‘yes’ please provide QCA with details)
Do you have a criminal record or are you currently under investigation by State, Territory,
Federal or International Police?
YES/NO*
If ‘yes’ please provide QCA with details)
*NOTE: A ‘yes’ answer to either of the last two questions will not necessarily exclude you from QCA
membership
Do you wish to list your professional details on the QCA website under counsellors for the coming year?
This listing is free.
Do you wish to have a special promotional listing which includes your photo or logo?
The annual fee for a promotional listing is $50 including GST.
YES/NO
YES/NO
Please email details as instructed on the website listing form attached.
CERTIFICATION
1. I certify that the above information is correct and my records will be made available if required.
2. I acknowledge that QCA requires each member to maintain high ethical and professional standards
when practicing as a counsellor. I have read the QCA Code of Ethics and I acknowledge that my
remaining a member of QCA depends upon my adhering to its requirements.
3. I acknowledge that should QCA receive a complaint about my professional standards or ethical
behaviour as a member of QCA, that they are required to investigate the matter. I am aware that QCA has
appointed an Ethics committee to deal with matters of this nature.
_____________________________________
Member’s signature
v10/7/15
_ __ ___/__ ___/__ __ __
Date
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Fees payable (please circle)
Membership renewal $99, $348, $265, $220 (incl GST) plus (optional) special weblisting $50
TOTAL
$__________
Tax invoice/receipts are issued for payment of fees.
Payment can be made either by:
1. Direct Deposit or Electronic Transfer to
Account name:
Queensland Counsellors Association Inc
Bank:
QT Mutual Bank
BSB:
804 002
Account No.:
1208791
IMPORTANT Please ensure that your name (surname first) appears in Direct Deposit or Electronic Transfer
reference details so a receipt can be issued. A record of your payment, together with the completed renewal
form, current supervision contract and PD log should then be posted to the Secretary at the address below.
OR:
2. Payment by cheque/money order - Please make payable to QCA Inc
Please post cheque together with completed renewal form, current supervision contract and PD log to:
QCA Inc
PO Box 3319
Bracken Ridge 4017
Office use only
Date received:
Amount:
Receipt no.:
Signed:
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QCA is a constituent Member Association of the Psychotherapy and Counselling Federation of Australia Inc.
(PACFA)
Website Listing Format
Listing on the QCA website is an option, available to Fellows, Clinical, Provisional and Associate members but not to Affiliate
members. There is no fee for a counsellor and/or supervisor listing. The annual fee for a promotional listing (includes a
photo or logo) is $50 including GST.
Please type your listing as plain text, worded exactly as you wish it to appear. Please use only the headings that appear
below. You can either use MsWord, or a similar word processor to create a text file or type your entry directly as an email
message.
Your listing can then be submitted either as an email, or as a file attached to an email to: qca@qca.asn.au
Please note that details to be listed on the QCA website cannot be submitted as hard copy, neither on paper nor by fax.
First Name
Last Name
Email
Membership Category
Web Site
Accredited Supervisor
Workplace Address
Suburb
Phone (w)
Mobile
Position
Qualifications
Counselling services (50 words maximum)
________________________________________________________________________________________
If you are a QCA endorsed Supervisor, do you wish to have/retain a separate Supervisor listing?
YES/NO
If you wish to apply for accreditation as a supervisor please go to the website as above.
Please email your photo or logo for a promotional listing as a separate file.
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