supervised practice: registration & agreement form - APS Member ...

SUPERVISOR DETAILSNormally it is expected that there is one (1) Supervisor. However, the maximum number of Supervisors at any onetime is two (2). If you currently have two (2) Supervisors a separate Registration and Agreement form is required fromeach Supervisor.Prof. c Assoc. Prof. c Dr c Mr c Mrs c Ms c Miss cFORMER NAME IF APPLICABLEFamily Name:Given Names: Date: / /Phone: (W)Phone: (H)Mobile: Please circle preferred contact: Work Home_ MobileFacsimile:Email:Home Address:State: Postcode:Work Address:State: Postcode:APS Membership No:Membership Grade:Date Elected to the College of Community Psychologists: / /If you are registered as a Supervisor with the College, please provide the date of registration: Date: / /If your Supervisor is not an approved Supervisor of the APS College of Community Psychologists, please request that theysubmit an ‘Application for eligibility as an APS College Supervisor’ form, prior to this form being submitted for processing.Highest relevant qualification completedInstitution:Award: Date: / /Estimate of supervisee’s current employment relevant to the application of the knowledge, theories and skills ofCommunity Psychology.Substantial c Moderate c Minimal c3OF 6

SUPERVISION ARRANGEMENTS (TO BE COMPLETED BY SUPERVISEE)Notes:1. A maximum of 10 hours of group supervision, with a minimum of 30 hours as individual supervision, can be counted.2. Evidence of Community College relevant individual and/or group supervision is required to be presented as a log bookthat includes a Supervisor’s signature3. Supervision is to be spread over the year, with an expectation of weekly-fortnightly supervision.4. An “Approved Supervisor” is a person who holds the grade of Member of the relevant College of at least two yearsstanding, or who has been eligible to hold the grade of Member of the relevant College for a minimum of two years.5. Supervisors who have not been approved must complete the ‘Eligibility for approval as a Supervisor’ form –transitiononly- and submit this as part of this application process.NB: This application for College membership cannot proceed until your Supervisor has been approved.Type of supervision:Individual: c No. of Meetings: Duration of meetings:Group*: c No. of Meetings: Duration of meetings:* Note that no more than 25% of meetings can be group supervisionFormat of supervision:Face-to-face**: c No. of Meetings: Duration of meetings:On-line (e.g. Skype): c No. of Meetings: Duration of meetings:Teleconferencing: c No. of Meetings: Duration of meetings:** Note, there must be a minimum of 50% face-to-face meetingsTotal number of supervision sessions:Total number of supervision hours:Reflecting on your learning experiences in your Masters of Community Psychology, describe the nature of your proposedwork and active CPD that will enhance and consolidate your learnings.Proposed work:Proposed active CPD:Goals of Supervision:(i.e. integrating work, CPD, professional issues etc into practice)General 1.2.3.Specific 1.2.3.LogbookIt is a requirement that a signed log book with the details of this supervision is regularly maintained, including the Supervisor’s signature.4OF 6

DECLARATION BY SUPERVISOR AND SUPERVISEEWe believe that the plan for supervision described above accords with the APS Guidelines on Supervision (2003).Supervisor’s Signature: Date: / /Supervisee’s Signature: Date: / /This statement will be retained on Society files.The APS College Assessment Team must be notified (by completion and submission of a new ‘Supervised Practice:Registration & Agreement’ – transition only – form) of any changes to employment and/or supervisory arrangements.PRIVACY STATEMENTProtecting Your PrivacyWe are committed to protecting your privacy, and the confidentiality andsecurity of the personal information held or collected by the Society.How we use your personal informationThe personal information provided by you on this application form willbe used:• to assess your eligibility for membership;• to update any personal information already held about you on ourdatabase;• to provide successful applicants with access to and information about arange of current and future membership benefits;• to provide the Society with data and statistics about its membership;• to include limited information in a publically accessible MembershipDirectory, and further information in an APS Members-only accessibleversion of the Membership Directory.If you do not provide us with this personal information, we may not be ableto process your application.How we collect personal informationIn addition to the information collected from you in this form, the Societymay also seek personal information from publicly available sources, suchas directories, or from other sources such as educational institutions,registration boards or employers, for the purpose of verifying informationprovided to the Society.When we disclose your personal informationWe may at times disclose your personal information to organisationsexternal to the Society where those organisations assist us to provideservices to you. Information disclosed to external organisations is doneon a limited basis and is provided with the agreement from those serviceproviders that they will maintain the security of that information and use itonly for the limited purpose for which it is disclosed.Accuracy and AccessThe Society strives to keep accurate records of the personal information wecollect. You have a right to access your personal information held by theSociety, subject to the exceptions listed in National Privacy Principle 6. If youwould like to do so please contact the Privacy Officer as set out below. Yourrequest will need to be put in writing for security and recording purposes.Membership DirectoryThe Society’s Membership Directory is not a publically searchable facility.Information included in the Directory may be provided upon request, asfollows. For Society members:• Your nominated contact phone number will be released to the publicupon request. (If you do not wish to have your telephone numberreleased to the public upon request, please ensure you have ticked theappropriate box on this form, updated your details in the “ManageYour Membership” section of our database, or sent an email tomembership@psychology.org.au.)• If you hold the membership grades of Member, Fellow or HonoraryFellow of the APS, your title, name, contact phone number, and yourmembership of APS Colleges will be included in the APS Members-onlyaccessible version of the Membership Directory available through theAPS website.• In response to a request from a psychologist registration board, theSociety may, at its discretion, disclose information held about yourqualifications, experience and practice as a psychologist.• The Society may seek your consent to have the same details as thoseincluded in the Membership Directory made accessible to otherallied health organisations for the purpose of increasing access byappropriately qualified professionals to psychologists for the purpose ofmaking referrals.Our Privacy PolicyFor further information about the Society’s privacy policy, refer to the APSwebsite at www.psychology.org.au. Copies of the APS Privacy Policy maybe downloaded from the website or obtained from the APS National Officeupon request.SEND FORM TO ...Once you have completed this form, please send it to:Attention:APS College Assessment TeamThe Australian Psychological Society LtdPO Box 38, Flinders Lane VIC 8009, AUSTRALIATelephone enquiries to APS Colleges on 03 8662 3300 or toll free 1800 333 497Email enquiries to collegeapplications@psychology.org.au5OF 6

OFFICE USE ONLYI hereby certify that the applicant is eligible forregistration of Supervision and that the Supervisor isan eligible Supervisor for the College of CommunityPsychologists./ /Name of assessor Signature of assessor DateTo be completed by the Administration Officer:DatesEntered in PivotalApplication received (date) / // /Due dates of progress reports (6 monthly)/ // /Due date of final report / /6OF 6