PO Box 1040
CIVIC SQUARE
ACT 2608
E: capacar2office@iinet.net.au
W: www.capacar.org.au
A member association of the Psychotherapy and Counselling
Federation of Australia Inc. (PACFA)
ABN: 50 615 178 347
CAPACAR INC. Membership Application FORM/ INVOICE
1st July 2015 – 30th June 2016
Please add all relevant details to update our membership system – please PRINT Clearly.
1.
Personal Details
Please add your details to update our membership system – please PRINT Clearly.
New M’Ship
Title:……
Renewal
Member number
Given Name:…………………….
Initial:…...
Family Name:…………………………
Company/Employing Organisation:……………………………………………………………………………
Postal address:……………………………………………….
Suburb:………………………………….. State:…….. Postcode: ……….Home Ph: ………………..
Work Ph: …………………………
Mobile: …………………….
Email 1………………………………………..
2.
Fax: ………………….
Email 2…………………………………
Membership category and fee – (tick category required - see Pages 5-6 for criteria)
Clinical Member $280.00 (includes $170.42 inc GST PACFA levy and $15.00 non-refundable application fee)
Associate $195.00
(includes $15.00 non-refundable application fee)
Student $85.00
Affiliated Member $65.00
(includes $15.00 non-refundable application fee)
Leave of absence $35.00
[Renewal Application can skip to No. 9]
3.
Employment – please indicate
Employed by an agency/organisation
Employed by a private practice
Self-employed in private practice
Working in another field
Other (eg. Student, retired, not employed, volunteer)
Please return this completed form by: Email: capacar2office@iinet.net.au;
Post to: CAPACAR Inc. Membership,
PO Box 1040, CIVIC SQUARE, ACT 2608.
Payments can be made by EFT, Cheque, or Money order.
1
PO Box 1040
CIVIC SQUARE
ACT 2608
E: capacar2office@iinet.net.au
W: www.capacar.org.au
A member association of the Psychotherapy and Counselling
Federation of Australia Inc. (PACFA)
ABN: 50 615 178 347
4. How long have you been practising as a counsellor?
Years [
] Months [
]
Please provide a brief summary of the work you do.
5. Do you offer professional supervision? Yes / No
Supervision qualifications (if any)
Institution
Qual/Award
Year completed
6. Professional Interests
One of CAPACAR’s visions is to provide members with access to other members with whom they can share their knowledge
or learn new skills. Please indicate your professional special interests:
7.
Grief and loss
Sexual abuse
Relationships
Group facilitation
Adolescent
Addictions/impulse control
Children
Domestic violence
Crisis/trauma
Personality disorders
Trauma
Other (please state)
Professional standing and membership of other relevant associations
Name of Association
Type of membership
Please return this completed form by: Email: capacar2office@iinet.net.au;
Post to: CAPACAR Inc. Membership,
PO Box 1040, CIVIC SQUARE, ACT 2608.
Payments can be made by EFT, Cheque, or Money order.
Member since
2
PO Box 1040
CIVIC SQUARE
ACT 2608
E: capacar2office@iinet.net.au
W: www.capacar.org.au
A member association of the Psychotherapy and Counselling
Federation of Australia Inc. (PACFA)
8.
Relevant training / Continuing education
Institution
9.
ABN: 50 615 178 347
Qual/Award
Yr. completed
Course Duration
No. Contact hrs.
Supervision.
Clinical Members are required to provide evidence of 10 hours (minimum) of appropriate supervision, relating to
clinical practice over the past 12 months. [see attached Supervision Log]
In training ………
Number of hours of supervision:
10.
After training ………
Total ………
Continuing Professional Development
Number of hours of CPD over previous 12 months:
[ ]
(Attach evidence of participation in 20 hours [min] of CPD)
11.
Indemnity Insurance
Applicants for Clinical and Associate Membership need to be covered by Counsellor’s or Psychotherapist’s
Professional Indemnity Insurance - either privately or through an employer (a copy to be attached to the
Membership Application).
a) Private - a photocopy of your Certificate of Currency or Policy Schedule
b) Employed - a photocopy of the Certificate of Currency or Policy Schedule of your employer’s
insurance.
12.
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?
13.
YES / NO
(If YES please provide details on a separate document).
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 document). 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.
Please return this completed form by: Email: capacar2office@iinet.net.au;
Post to: CAPACAR Inc. Membership,
PO Box 1040, CIVIC SQUARE, ACT 2608.
Payments can be made by EFT, Cheque, or Money order.
3
PO Box 1040
CIVIC SQUARE
ACT 2608
E: capacar2office@iinet.net.au
W: www.capacar.org.au
A member association of the Psychotherapy and Counselling
Federation of Australia Inc. (PACFA)
14.
ABN: 50 615 178 347
Certificate disclaimer
Membership certificates will be sent to members via email.
15.
Declaration – please read carefully before signing
The information on this form is true and correct to the best of my knowledge. I agree that any information
provided on this form and accompanying documentation may be verified. I have read and agree to abide by the
CAPACAR Inc. Code of Ethics.
Signature
Date
The content of this application, when completed, is CONFIDENTIAL, and is to be viewed only by those appointed by the
CAPACAR Inc. to conduct the application assessment and associated processes.
Payment method – please tick one
Cheque
Money order
EFT (BSB: 112-908 Account no: 438 462 859,
Reference: include Surname or Membership Number
[note EFT payment receipt number here ……………..………..….]
OFFICE USE Receipt number
Date recorded on database…………………….
GST does not apply to membership fees
Applicants should direct any membership inquiries to the Membership Registrar at
capacar2office@iinet.net.au
Please return this completed form by: Email: capacar2office@iinet.net.au;
Post to: CAPACAR Inc. Membership,
PO Box 1040, CIVIC SQUARE, ACT 2608.
Payments can be made by EFT, Cheque, or Money order.
4
PO Box 1040
CIVIC SQUARE
ACT 2608
E: capacar2office@iinet.net.au
W: www.capacar.org.au
A member association of the Psychotherapy and Counselling
Federation of Australia Inc. (PACFA)
ABN: 50 615 178 347
Membership Categories
Clinical Member – 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.
(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).
(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 (RPL)
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 be admitted as
a member based on recognition of this prior learning.
b. Have practised as a counsellor or psychotherapist and received at least 50 hours of appropriate
supervision linked to 200 hours client contact
These requirements comply with PACFA’s minimum requirements for professional 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
accepted)
e) Evidence of participation in appropriate supervision and number of hours completed (CAPACAR log or
letter/s from supervisor/s may be tendered as evidence)
f) Evidence of participation in Continuing Professional Development
g) Evidence of Current Professional Indemnity Insurance
.
Please return this completed form by: Email: capacar2office@iinet.net.au;
Post to: CAPACAR Inc. Membership,
PO Box 1040, CIVIC SQUARE, ACT 2608.
Payments can be made by EFT, Cheque, or Money order.
5
PO Box 1040
CIVIC SQUARE
ACT 2608
E: capacar2office@iinet.net.au
W: www.capacar.org.au
A member association of the Psychotherapy and Counselling
Federation of Australia Inc. (PACFA)
ABN: 50 615 178 347
Associate – 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 leading to Clinical Membership.
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
Evidence of participation in Continuing Professional Development
Evidence of Current Professional Indemnity Insurance (if working as a counselling)
Student member – open to people who are currently studying to become counsellors or
psychotherapists.
a) Completed application form.
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 Constitution and Code of Ethics.
b) Completed application form.
Leave of Absence – this category of membership is open to members wanting 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.
c) Completed application form.
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.
Eligible applications are to be forwarded to PACFA. Forms can be downloaded from the PACFA Website.
Please return this completed form by: Email: capacar2office@iinet.net.au;
Post to: CAPACAR Inc. Membership,
PO Box 1040, CIVIC SQUARE, ACT 2608.
Payments can be made by EFT, Cheque, or Money order.
6
PO Box 1040
CIVIC SQUARE
ACT 2608
E: capacar2office@iinet.net.au
W: www.capacar.org.au
A member association of the Psychotherapy and Counselling
Federation of Australia Inc. (PACFA)
ABN: 50 615 178 347
CAPACAR Clinical Supervision Log
Name of Supervisee:
Name of Supervisor:
Phone/email:
Phone/email:
Period (From-To)
Client hours
Supervision hours
Supervisors signature
I confirm the contents of this form are a true and accurate record.
Signed __________________________________________
CAPACAR [ ] Clinical member
Date: ____________________
[ ] Associate member
[tick one]
Please return this completed form by: Email: capacar2office@iinet.net.au;
Post to: CAPACAR Inc. Membership,
PO Box 1040, CIVIC SQUARE, ACT 2608.
Payments can be made by EFT, Cheque, or Money order.
7