National Carer Counselling Program – NSW

A Commonwealth Government Initiative

EXPRESSION OF INTEREST – CONTRACT COUNSELLOR

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COUNSELLOR DETAILS (please provide copies of all relevant documentation)

Individual / Business Name______

ABN Number______

Postal Address______

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Phone No______Fax No ______

Email ______

Practice address/es and availability details______

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Proposed session cost:

Individual: ______. (Please tick) ☐ No GST ☐GST included☐Plus GST

Couple: ______. (Please tick)☐No GST ☐GST included ☐Plus GST

PRACTICE PROFILE

Current services provided______

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Current sources of referrals______

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Years in operation______

Supervision arrangements (include qualifications of supervisor and frequency)______

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Details of current insurance cover policies______

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A) Professional Indemnity______

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B) Public Liability______

Details of current Police and Working with Children’s Checks ______

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PROFESSIONAL QUALIFICATIONS (Please provide details of any relevant tertiary qualifications)

Institution______

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Date ______

Institution______

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Date ______

Institution______

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Date ______

Professional Registration/Membership (Please provide details and attach copies of relevant Professional bodies that you are registered with or have membership with currently)

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Medicare Registration (Please provide details if applicable)______

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PROFESSIONAL EXPERIENCE

Details of supervised counselling experience______

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Details of areas of counselling specialisation______

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Details of preferred client groups______

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Details of key counselling frameworks______

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Details of any other current employment

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Details of any relevant previous employment ______

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Please provide information about current/previous work with carers and caring related issues

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Please state any experience delivering therapeutic support to Culturally and Linguistically Diverse (CALD), Aboriginal and Torres Strait Islander (ATSI) or Gay, Lesbian, Bisexual, Transgenderand Intersex (GLBTI) communities.

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REFEREES

Please supply the names and contact details of at least two referees who can comment on your counselling experience

Referee 1 (Please include the nature and period of relationship) ______

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Referee 2 (Please include the nature and period of relationship)

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Signature of Applicant______

Date:

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Version 2 EOI Brokered Counsellor Form July 2016 1