Supervision Form

Name & Preferred Pronoun: *

Organisation / Private Practice Name:

Workplace Position Held / Title:

Work / Practice Address: *

Postcode *

Mobile phone: *

Alternate Phone:

Email *

Emergency Contact Name:

Emergency Contact Phone:

RELEVANT PROFESSIONAL QUALIFICATIONS:

CLIENT BASE / SPECIALISATION / HOURS:

Please indicate the type of client work undertaken, together with an approximation of current (or anticipated) workload. Eg ‘Working face to face with adults averaging 12 client contacts per week’. Please also mention area of specialisation.

PROFESSIONAL ORGANISATION(S) & CODE of ETHICS:

Please list any professional organisations and/or organisational code of ethics or framework that informs your practice. For example: PACFA, ACA or NDIA (NDIS) Code of Ethics.

THEORETICAL MODELS

Please indicate the key models which inform your clinical practice.

PROFESSIONAL LIABILITY INSURANCE:

Please list the name of Insurance Company, policy number and expiry date of policy. (If covered by Organisation’s Professional Indemnity Insurance please indicate below)

PAYMENT DETAILS: *

Employer organisation (if applicable) | Name for invoice addressee | Email address (of organisation) | Payment on the day (Required for private practitioners or those not covered by an employer)

Ready to get started?

What keeps you from getting started?
What’s holding you back from your next big adventure or the change you have been wanting?
Do you have a feeling of not being good enough?
A fear of being criticized by others?

“Imperfect action beats non-action every time.” – President Harry Truman. So if you are ready then I am too.