OFFICE USE ONLY
Approved:
(Education
Officer)
THE NEW SOUTH WALES INSTITUTE OF PSYCHIATRY
Student No:
(Data Entry)
__ __ - __ __ __ __
COM002 CONSUMER ADVOCACY COURSE
APPLICATION FORM
PERSONAL INFORMATION
Date of
Mr/Mrs/Miss/Ms
Birth:
First Name & Initial
Last Name
Private Address:
State:
Phone: (H)
(M)
Fax:
Email:
Post Code:
If relevant, please fill in the following section:
Employer, (including voluntary consumer or carer work):
Employer (including voluntary consumer or carer work)
OR
Sponsoring Organisation (a service that supports you to attend this workshop)
Employer or
Organisation:
…………………………………………………………………………………………………………………………………..
Work Address:
…………………………………………………………………………………………………………………………………..
…………………………………………..………………………… State: ……….………. Postcode: …………………
Phone: ………………………………………… Fax: ……………………………………………. Email: …………………………………………
Employ
er,
Experience ( Please tick relevant boxes):
(includi
Consumer Advocacy
ng
Number of months in this position:
voluntar
y
Consumer
Representation
consum
Number of months in this position:
er or
Peer Support Work
carer
Number of months in this position
work):
Active involvement in mental health
0-2
3-5
6-9
10+
0-2
3-5
6-9
10+
0-2
3-5
6-9
10+
0-2
3-5
6-9
10+
organisations and/or consumer groups
Number of months in this position:
Current consumer title:
Current work setting:
Public
Private
Community
NGO
Voluntary
Other
Previous
Consumer
Committee
Consumer
training (Please
Advocacy
Representation
Resources (eg
tick the relevant
websites, books
box for each
etc)
Consumer
Mental Health
Consumer
Networks
Services
rights and
Structures and
related
Policy
legislations in
mental health
category):
None
None
None
None
None
None
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Extensive
Extensive
Extensive
Extensive
Extensive
Extensive
Any other qualifications? Please outline:
ELIGIBILITY CRITERIA:
The only requirement for admission to the Consumer Advocacy Course is that the applicant is or has been a consumer of
mental health services, and has personally experienced a mental health problem.
I meet the criteria for eligibility to the Consumer Advocacy
Course and I have read the workshop brochure or had it read to
me (please sign)
(If you are unsure as to whether you qualify for the course, please contact Marion at the Institute of Psychiatry).
GENERAL:
In relation to your participation in mental health consumer activity, such as consumer advocacy or representation, which
level accurately describes you?
Beginner
Intermediate
Advanced
OTHER INFORMATION:
How did you find out about this course?
Institute
Work
Journal Ads
Notices
Website
brochure
Course fees are being paid by:
Employer
Self
Organisation
Reasons for applying for this course:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Other
PAYMENT DETAILS
I enclose my cheque/money order for the amount of: $____________
made payable to The NSW Institute of Psychiatry
OR
Please debit my credit card for the amount of: $_____________
Please circle card type: VISA
Card No:
BANKCARD
MASTERCARD
__ __ __ __ / __ __ __ __ / __ __ __ __ / __ __ __ __
Name on Credit Card:________________________________
Expiry Date: __ __ /__ __
CCV No: __ __ __
Signature: __________________________________________________
FEE POLICY CONDITIONS
PLEASE NOTE THE FOLLOWING ABRIDGED FEE POLICY. POLICIES ARE FULLY EXPLAINED IN THE 2015 COURSE HANDBOOK.
APPLICATIONS: All courses require Institute application forms - phone bookings are NOT accepted. Application Forms are available by
either downloading from the Web or by contacting the Institute for an application to be forwarded to you. Signing of the application
indicates the students’ acceptance of the rules and policies of the Institute.
PAYMENT OF FEES: Students are encouraged to pay their fees in advance.
INVOICES: NSWIOP invoices the student not the organisations or sponsors of individual students. It is therefore the responsibility of the
student to ensure payment of course fees.
WITHDRAWALS: Notification of an applicant's intention to withdraw from the workshop must be made in writing.
Withdrawal by telephone or by implication is not acceptable under any circumstances. The following Withdrawal fees and conditions apply:
Withdrawal 10 working days or more prior to workshop commencement - fees will be refunded in full. Withdrawal 6-9 working days prior
to workshop commencement – liable for 20% of the Full Fee for the workshop. Withdrawal 5 working days or less prior to workshop
commencement - liable for 100% of Full Fee for the workshop
COURSE CANCELLATION: The Institute reserves the right to cancel a course if there are insufficient applications. A full refund will be made
of fees paid. A decision to cancel a course will be made 5 working days prior to commencement.
UNPAID FEES: It is the responsibility of students to ensure that fees are paid on or before the commencement of the course. Any student
who owes course fees and who has received notice of the outstanding amount will be referred to the appropriate Debt Recovery agency.
CHANGE OF ADDRESS: It is the responsibility of students to inform us in writing of a change of address prior to workshop commencing.
SIGNATURE: …………………………………………………………
DATE: ………………
APPLICANTS WILL RECEIVE WRITTEN CONFIRMATION OF ENROLMENT
Please forward completed application form to:
Marion Young
NSW Institute of Psychiatry
Locked Bag 7118, Parramatta BC NSW 2124
Telephone: (02) 9840 3833 Fax: (02) 9840 3838
Email: marion.young@nswiop.nsw.edu.au
Website: www.nswiop.nsw.edu.au