PERSONAL DETAILS BASIS FOR APPLICATION

Transcription

1 APPLICATION FM (for transitional arrangements only) APS SUPERVISED PRACTICE ASSOCIATE MEMBER - MASTERS ROUTE APS COLLEGES PERSONAL DETAILS Dr c Mr c Mrs c Ms c Miss c Other c Family name: Former name (if applicable): Given names: Date of birth: / / Preferred mailing address: Other details: Position/title: Organisation: State: Postcode: APS Member Number: APS Grade: Preferred telephone:( ) Mobile: BASIS F APPLICATION Master of Psychology 1a. I have completed an APAC accredited and College approved Master of Psychology in: 1b. I have completed an APAC accredited and College approved PhD/Master of Psychology in: c Clinical Neuropsychology c Counselling Psychology c Health Psychology c Clinical Psychology c Educational & Developmental Psychology c Organisational Psychology c Community Psychology c Forensic Psychology c Sport & Exercise Psychology AND 2. I wish to be elected to the grade of Associate Member of this College YES c 1 OF 5

2 APS MEMBER WITH AN APAC ACCREDITED AND COLLEGE APPROVED MASTERS PHD/MASTERS IN PSYCHOLOGY These guidelines have been prepared to assist applicants for the grade of Associate Member of an APS College under the transition rules. The provisions of the relevant transition rules are as follows (APS Generic Rules for Colleges 2011): 9. TRANSITIONAL PROVISIONS F MEMBERSHIP 9.1 To qualify for election to the grade of Member of a College under the previous criteria for grades of membership of a College as set out in the Generic Rules in force and effect on 30 September 2010, an applicant must have: (a) completed an Accredited and College Approved Masters program or the coursework and practicum components of a combined PhD/Masters program in psychology in the specialist field of the College, and: (i) have commenced a supervision program by 30 September 2010; and (ii) notified the Society of having commenced supervision by 30 December 2010; and (iii) subsequently completed that supervision program by 30 June 2013; and (iv) the supervision program must be assessed by the College as sufficient for qualification for election to the grade of Member of that College; (b) been enrolled in an Accredited and College Approved postgraduate professional psychology program on 30 June 2010 and completed all degree requirements and any necessary period of Supervised Practice; (c) completed an Accredited and College Approved postgraduate professional psychology program between 30 June 2005 and 30 June 2010 and completed any necessary period of Supervised Practice by 30 June Note: To progress from Associate Member grade to Member grade of a College, under the transition rules, the successful completion of one year full time equivalent Supervised Practice is required. This Supervised Practice can be registered with the APS by completing the APS Supervised Practice: Registration and Agreement Form. Progress reports are required at six (6) monthly intervals. Supervised Practice definition in the Generic Rules for Colleges: Supervised Practice means, for each one year full-time equivalent; a) A minimum of 40 hours of supervision during psychological practice by an *Approved Supervisor; and b) A minimum of 40 hours **active professional development during psychological practice; and c) Such requirements may be further stipulated in the Standing Orders of the Society. Approved Supervisor (Transition provisions under Standing Orders) * Approved Supervisor means a person holding the grade of Member of the relevant College of at least two years standing, or who has been eligible to hold the grade of Member of the relevant College for a minimum of at least two years, who: (a) has completed a training program in psychology supervision approved by the Society^; (b) holds general registration as a psychologist without restriction or conditions; (c) is not a member of the supervisee s immediate family or household; and (d) is not or has not been engaged in a therapeutic relationship with the supervisee. ^ At the time that a training program in Supervision is approved by the Society, any person who at that time is an Approved Supervisor will have until 30 June 2013 to complete the training program. Any person who has not previously been approved as a supervisor for the relevant College at the time a training program in psychology supervision is approved by the Society, will have to complete the training program in addition to fulfilling the other requirements for approval as a supervisor prior to being approved as a supervisor for the relevant College. During psychological practice includes the provision of direct clinical care or using professional knowledge in a direct nonclinical relationship with clients, working in management, administration, education, research, advisory, regulatory or policy development roles, and any other roles that impact on safe, effective delivery of services in the profession. **Active professional development means:.. activities that engage the participant in active training through written or oral activities designed to enhance and test learning - refer APS CPD requirements: 2 OF 5

3 ACADEMIC RECD Please list below all undergraduate and postgraduate qualifications in psychology that you have been awarded. Name of institution Qualification(s) Month and year completed IMPTANT! Documentation of qualifications If you do not submit supporting documentation in the manner outlined below, your application cannot be processed. Transcripts For each degree, please attach official academic transcripts, that itemise each subject undertaken and show completion or conferral of each degree. Academic transcripts may be submitted in either original format or as a *certified photocopy. Documentation submitted to the APS in support of your application will not be returned. If your transcripts are in another name to that listed on the front of this form, please provide certified documentation of your change of name (for example, Marriage Certificate or Change of Name Certificate). Please notify the College Assessment Team if you believe the APS already holds the relevant transcript(s). *Certified photocopy Photocopies of documentation must be certified as true copies of the original by one of the following certifying officers: Member of the Society (MAPS, FAPS, Hon FAPS), accountant, Justice of the Peace, lawyer, pharmacist, physiotherapist, police officer, psychologist. Each photocopied page should be marked certified as a true copy of the original and include the signature and printed name, profession, registration number and telephone number of the certifying officer. The certifying officer must not be a family member or spouse. Major research thesis title(s) Thesis Title Supervisor s Name 3 OF 5

4 PROPOSER F APPLICANT As part of the APS College application process, all applicants need to be proposed by one current Member of the APS College they are applying for. I, the undersigned, propose and believe that she/he is a fit and proper person to be elected to the grade of Associate Member of the APS College of (insert College name) Psychologists. Last Name: Given Name: Telephone W: ( ) Mobile: ( ) YES c NO c APS College Grade of Member: APS Member Number: Signature: Date: / / APPLICANT S DECLARATION YES NO (a) Are you under investigation by the Psychology Board of Australia (PsyBA) as the result of a notification? (b) Have you had an adverse finding made against you by the PsyBA? (c) Have you been convicted of an offence involving a criminal charge, or is there any charge pending? Note: If you responded YES to any of the above questions, please attach an explanation to this application (including details of the outcome). Mark it IN CONFIDENCE and address it to the Executive Manager: Science, Education and Membership. In evaluating your application, the Executive Manager: Science, Education and Membership will consider your response to these questions and may request further information. A positive answer to any of the above questions will not automatically result in rejection of the membership application. Each application will be considered individually. I hereby declare that: 1. All information submitted by me in this application is true to the best of my knowledge. I understand that any misleading statement, or omission, may be cause for rejection of this application. 2. I understand that if my application is unsuccessful, or if I withdraw or don t complete my application, I will be charged a processing fee of up to a maximum of $ If I become a Member of an APS College, I will be bound by the Generic Rules for Colleges and any other rules or regulations adopted by the APS including the Terms and Conditions for APS College Applications and the APS Privacy Policy (Copies of the above documents are available on the APS website or alternatively from the National Office of the APS). 4. I have read and understood the Terms and Conditions for APS College Applications and the APS Privacy Policy. Signature: Date: / / PAYMENT Membership for the Subscription year ending 31 May 2016 The College membership assessment fee includes complimentary College membership. There are three payment periods for Members, depending on when you join: If you join between 1 June 2015 and 30 November 2015 _ you pay $ (incl GST) If you join between 1 December 2015 and 10 February 2016 you pay $ (incl GST) If you join between 11 February 2016 and 31 May 2016 _ you pay $179.00^ (incl GST) ^ When joining between 11 February and 31 May 2016 you will receive College Membership until 31 May 2017 which means getting up to 3 months complimentary College Membership. 1. If you are paying by cheque, please make it payable to: The Australian Psychological Society Limited (Australian dollars only please). 2. If you are paying by credit card, please complete the following details: c APS American Express c American Express c Mastercard c VISA Amount: $ Card number: Expiry date: / Card holder s name (please print clearly): Card holder s Signature: Date: / / The Australian Psychological Society Limited ABN: This document becomes a Tax Invoice for GST upon payment. Please photocopy this form for your records. 4 OF 5

5 COLLEGE MEMBERSHIP DIRECTY The College has developed a Membership Directory for each College which assists members to network and connect within their College. Only members of the same College can access the College Membership Directory. The following details would be disclosed: Title, First name, Last name, Telephone number, Work place, State/Territory. Further options include provisions for expressing interest in peer consultation and providing supervision to provisional psychologists. c Please tick the box if you would like to be listed in the College Membership Directory. CHECKLIST Processing is dependent on receipt of all of the following documents. Please tick boxes to indicate inclusion: c This completed application form c Completed academic record c Certified copies of all relevant transcripts c Supervised Practice: Registration and Agreement form (if applicable) c Application for Approval as a Supervisor form (if applicable) c Proposers signatures and details c Signed declaration c Payment of fee SEND FM TO... Once you have completed this form, please send it together with all relevant documents and payment to: Attention: APS College Assessment Team The Australian Psychological Society Limited PO Box 38, Flinders Lane VIC 8009, AUSTRALIA Telephone enquiries to APS Colleges on or toll free enquiries to [email protected] Application outcome: APPROVED c NOT APPROVED c Name of assessor Signature of assessor Date: / / 5 OF 5 15APSCOL-F-SP-T-AMMR-P2