1 Submission no. Application for Accreditation as a Family Dispute Resolution Practitioner Final Accreditation Standards For assistance in completing this application, please refer to the: (i) Guide to completing an Application for Accreditation as a Family Dispute Resolution Practitioner (available from (ii) Commonwealth Statutory Declaration (available at the end of this form) Send completed application form to: Practitioner Registration Unit Dispute Management Family Pathways Access to Justice Division Attorney-General s Department National Circuit Barton ACT 2600 Section A. Name and Personal Contact Details 1. Title: 2. First name(s): 3. Family name: 4. Postal Address: 5. Contact phone number(s): Business Hours Mobile (optional) 6. tification address: Primary Secondary (optional) 7. Date of Birth: 8. Are you male or female? Male Female
2 Section B. Child-related Employment and Working with Children 9. Are you prohibited under the law of a State or Territory from being employed in child-related employment or working with children? 10. Have you complied with the requirements of the applicable law in the State(s) and/or Territory(s) in which you provide family dispute resolution services in relation to employment of persons in child-related employment or working with children? Please attach evidence of compliance Section C. Criminal Convictions 11. Have you been convicted of an offence involving violence to a person? 12. Have you been convicted of a sex related offence, including rape, sexual assault, indecent assault, unlawful sexual acts with or upon minors, child pornography, procuring or trafficking of a child for indecent purposes or being knowingly concerned with the prostitution of a child? Please attach evidence of compliance Section D. Registration Status 13. Did you register as a family dispute resolution practitioner before 1 July 2009? (Complete Section E) (Complete Section F) Section E. Registered before 1 July What is your registration number/s? (If you use more than one please provide all numbers) 15. If a registration number is that of an approved or designated organisation for which you provide family dispute resolution services, provide the name of the organisation: te: If you also provide family dispute resolution services independently of a registered or government funded organisation you must also complete Section G Complaints Mechanism and Professional Indemnity. 16. If you have been assessed as competent by a Registered Training Organisation against the 3 specified units of the Vocational Graduate Diploma of Family Dispute Resolution (CHC80207) or the equivalent units certified by a higher education provider*, please attach evidence of competency for each unit. *The list of certified higher education providers is available at Please complete Section H Signature and the Statutory Declaration at the end of this form and submit your application to the Practitioner Registration Unit. You may also choose to complete Attachment A (optional).
3 Section F. t Registered before 1 July Please indicate the qualification/s you have completed: Attach a copy of your qualification/s and/or academic transcript Vocational Graduate Diploma of Family Dispute Resolution (CHC80207) or the equivalent qualification from a certified higher education provider*. A higher education award, for example, law, psychology, social work, conflict management, mediation, dispute resolution or in a field or discipline relevant to the provision of family dispute resolution. Please provide the full name of the qualification: Assessed as competent by a Registered Training Organisation against each of the six compulsory units of competency of the Vocational Graduate Diploma of Family Dispute Resolution (CHC80207) or completed the equivalent units certified by a higher education provider*. Accredited by a Recognised Mediation Accreditation Body under the National Mediator Approval Standards. Name of the accreditation body and year accredited: Year: *The list of certified higher education providers is available at Please complete Section G Complaints Mechanism and Professional Indemnity, Section H Signature and the Statutory Declaration at the end of this form and submit your application to the Practitioner Registration Unit. You may also choose to complete Attachment A (optional).
4 Section G. Complaints Mechanism and Professional Indemnity 18. Complaints mechanism: What is the name of the body(ies) that will be handling any complaints made about all the family dispute resolution services you provide (list all relevant bodies)? 19. Please give details of the process/es you have in place for clients to make complaints about the family dispute resolution services you provide. Compliant with Standard 11 of the Family Relationships Services Program Other Internal complaints process (Commonwealth funded services only) Complaints mechanism through Professional Association Other, please provide details 20. Professional Indemnity: Do you have professional indemnity insurance or statutory indemnity? 21. Please indicate type of insurance and provide details: Professional indemnity insurance through membership Professional indemnity insurance through employer Statutory indemnity Details: Section H. Signature Signature: Date: Please complete the Commonwealth Statutory Declaration and return it with this application form. Your application will not be processed until all documents are received.
5 Privacy tice The Attorney-General s Department is collecting the information requested in the application and Commonwealth statutory declaration included in this package to: assess your suitability to be accredited as a family dispute resolution practitioner for the purpose of issuing certificates under section 60I of the Family Law Act 1975 enable the public to locate registered family dispute resolution providers (no details about individuals who provide services on behalf of an approved or designated organisation will be publicly available unless the organisation confirms otherwise) enable the courts to verify that certificates under section 60I of the Act are issued by persons authorised under the Act to do so monitor compliance with conditions of accreditation, and compile reports on workforce statistics relating to the family dispute resolution services sector. Upon registration, and with your agreement, the information provided in the application form denoted by an symbol will be published on Family Relationships Online. In addition, if you are allocated a registration number, this will be accessible by the Federal Magistrates Court, the Family Court of Australia and the Family Court of Western Australia, in order to allow them to verify the legitimacy of certificates filed pursuant to section 60I of the Act. Registration numbers of Registered organisations will also be accessible by the courts. If your application is unsuccessful you will be notified in writing and provided with reasons. If you decide to appeal the decision to refuse registration, the Attorney-General s Department will, if required, forward a copy of your application to the Administrative Appeals Tribunal or the Federal Court of Australia.
6 Public Availability (Optional) Attachment A Registered family dispute resolution practitioners may wish to make information about their services available to members of the public through Family Relationships Online (www.familyrelationships.gov.au). If you would like your details to be available on Family Relationships Online, please complete this Attachment A. If you provide services from more than one outlet, complete Attachment A for each outlet. Where you are completing details for more than one outlet, please ensure that there is something included in the business or practice name to distinguish each outlet. For example, Jo Bloggs & Co. Parramatta, Jo Bloggs & Co. Blacktown An eye symbol beside a field indicates that upon registration, the information in the field will be available, with your permission: Do you agree to the items identified in this form with the symbol being publicly available upon registration? (please complete this Attachment A) Complaints Mechanism and Outlet Details 1. Complaints mechanism: What is the name of the body that will be handling any complaints made about the family dispute resolution services you provide from this outlet? 2. Please give details of the process you have in place for clients to make complaints about the family dispute resolution services you provide. Compliant with Standard 11 of the Family Relationships Services Program Other Internal complaints process (Commonwealth funded services only) Complaints mechanism through Professional Association Other, please provide details
7 3. For this outlet, do you have professional indemnity insurance or statutory indemnity? 4. Please indicate type of insurance and provide details: Professional indemnity insurance through membership Professional indemnity insurance through employer Statutory indemnity Details: 5. Business/practice name (includes first name and surname entered on the first page of the form): 6. Physical address: Town: State/Territory: Post Code: 7. Is your business postal address different to that set out above? (go to Question 9) 8. Business postal address: Town: State/Terr: Post Code: 9. Business telephone number (for public use): 10. Office-use only telephone number (optional): (Question 10 is for official use by the Attorney-General's Department and the Family Relationship Advice Line only. This number will not be accessible by the public.)
8 11. Business mobile number (optional): 12. Business facsimile number (optional): 13. Toll free telephone number (optional): 14. TTY (optional): 15. Public (optional): 16. Web address (optional) For Questions 17, 18 & 19, multiple boxes may be selected. 17. Which of the client groups listed below do you provide service to? Families and Children Adult family members Extended Families Other, please specify: 18. In which of the following areas do you provide services? Indigenous service Family separation Parenting arrangements Child support disputes Cases involving high conflict Property Legally assisted negotiations Culturally specific services, please specify: Other, please specify:
9 19. How are you able to deliver your services to clients? Face to Face Telephone Online Video conferencing Other, please specify: Outlet Access Details 20. Opening hours: By negotiation is not suitable for inclusion on Family Relationships Online. Please provide opening hours for days where this may apply. Monday Tuesday Wednesday Thursday Friday Saturday Sunday Day Open Close 21. Service coverage: You should indicate all the geographical areas in which this outlet provides family dispute resolution services by identifying either the appropriate location(s) and/or the appropriate postcode(s). by location: by postcode:
10 22. Is there wheelchair access at this outlet? 23. Is childcare available at this outlet? 24. Could an interpreter be made available at this outlet? 25. Is there parking available at this outlet? 26. Is there a bus stop within walking distance of this outlet? 27. Is there a taxi rank within walking distance of this outlet? 28. Is this outlet accessible by train? 29. Is this outlet accessible by tram? 30. How are services charged at this outlet? (Select one only) Free Charged Free and Charged If there is a cost associated with the service, please provide details. Include as much information as practicable (eg. there may be a sliding cost scale depending on ability to pay). Amounts should be specified. Your organisation can update these details at any time. 31. Additional cost information: 32. Other information (optional):
11 Commonwealth of Australia STATUTORY DECLARATION Statutory Declarations Act Insert the name, address and occupation of person making the declaration 2 Set out matter declared to in numbered paragraphs I, 1 make the following declaration under the Statutory Declarations Act 1959: 2 (1) I have completed the attached document Application for accreditation as a Family Dispute Resolution Practitioner Final Accreditation Standards and to the best of my knowledge the information included in the application form is true and complete. (2) Where I have provided copies of evidence or documentation in support of my application, those documents are true copies of the originals. (3) I have the appropriate personal qualities to perform the functions and duties of a family dispute resolution practitioner. (4) I am of good character and I have not engaged in conduct that is likely to bring family dispute resolution into disrepute. (Examples include, having an appropriate standing in the community, being of good fame and character, being regarded as honest and fair, and not engaging in conduct that would negatively impact on the public reputation of family dispute resolution practitioners.) I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence under section 11 of the Statutory Declarations Act 1959, and I believe that the statements in this declaration are true in every particular. 3 Signature of person making the declaration 4 Place 5 Day 6 Month and year 7 Signature of person before whom the declaration is made (see over) 3 Declared at 4 on 5 of 6 Before me, 7 8 Full name, qualification and address of person before whom the declaration is made (in printed letters) 8 te 1 A person who intentionally makes a false statement in a statutory declaration is guilty of an offence, the punishment for which is imprisonment for a term of 4 years see section 11 of the Statutory Declarations Act te 2 Chapter 2 of the Criminal Code applies to all offences against the Statutory Declarations Act 1959 see section 5A of the Statutory Declarations Act 1959.
12 A statutory declaration under the Statutory Declarations Act 1959 may be made before (1) a person who is currently licensed or registered under a law to practise in one of the following occupations: Chiropractor Dentist Legal practitioner Medical practitioner Nurse Optometrist Patent attorney Pharmacist Physiotherapist Psychologist Trade marks attorney Veterinary surgeon (2) a person who is enrolled on the roll of the Supreme Court of a State or Territory, or the High Court of Australia, as a legal practitioner (however described); or (3) a person who is in the following list: Agent of the Australian Postal Corporation who is in charge of an office supplying postal services to the public Australian Consular Officer or Australian Diplomatic Officer (within the meaning of the Consular Fees Act 1955) Bailiff Bank officer with 5 or more continuous years of service Building society officer with 5 or more years of continuous service Chief executive officer of a Commonwealth court Clerk of a court Commissioner for Affidavits Commissioner for Declarations Credit union officer with 5 or more years of continuous service Employee of the Australian Trade Commission who is: (a) in a country or place outside Australia; and (b) authorised under paragraph 3 (d) of the Consular Fees Act 1955; and (c) exercising his or her function in that place Employee of the Commonwealth who is: (a) in a country or place outside Australia; and (b) authorised under paragraph 3 (c) of the Consular Fees Act 1955; and (c) exercising his or her function in that place Fellow of the National Tax Accountants Association Finance company officer with 5 or more years of continuous service Holder of a statutory office not specified in another item in this list Judge of a court Justice of the Peace Magistrate Marriage celebrant registered under Subdivision C of Division 1 of Part IV of the Marriage Act 1961 Master of a court Member of Chartered Secretaries Australia Member of Engineers Australia, other than at the grade of student Member of the Association of Taxation and Management Accountants Member of the Australasian Institute of Mining and Metallurgy Member of the Australian Defence Force who is: (a) an officer; or (b) a non-commissioned officer within the meaning of the Defence Force Discipline Act 1982 with 5 or more years of continuous service; or (c) a warrant officer within the meaning of that Act Member of the Institute of Chartered Accountants in Australia, the Australian Society of Certified Practising Accountants or the National Institute of Accountants Member of: (a) the Parliament of the Commonwealth; or (b) the Parliament of a State; or (c) a Territory legislature; or (d) a local government authority of a State or Territory Minister of religion registered under Subdivision A of Division 1 of Part IV of the Marriage Act 1961 tary public Permanent employee of the Australian Postal Corporation with 5 or more years of continuous service who is employed in an office supplying postal services to the public Permanent employee of: (a) the Commonwealth or a Commonwealth authority; or (b) a State or Territory or a State or Territory authority; or (c) a local government authority; with 5 or more years of continuous service who is not specified in another item in this list Person before whom a statutory declaration may be made under the law of the State or Territory in which the declaration is made Police officer Registrar, or Deputy Registrar, of a court Senior Executive Service employee of: Sheriff (a) the Commonwealth or a Commonwealth authority; or (b) a State or Territory or a State or Territory authority Sheriff s officer Teacher employed on a full-time basis at a school or tertiary education institution
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