New Practitioner Details Form

NEW Practitioner Details

Your Full Legal Name*
Prefix First Middle Last Suffix
Preferred Name
What name do you prefer to be called?
Date of Birth*
Date Format: DD slash MM slash YYYY
Your Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Current Role or Occupation
Or, what you spend most of your time doing
Please list Languages in which you are fluent or confident (English is Essential)
Relationship Status (optional)
Next of Kin
Please provide details for an emergency contact that lives closest to you and whom you trust.
Name
First Last
Phone
Email
Current Practice
Are you currently practicing in your field of expertise?*
- Yes, I have a current client base
- Yes, current client base would remain with my current practice
- Yes, but I'm new to 'private practice'
- No, wanting to establish a new client base
Name & Location of current practice (if applicable)
Do you currently have appropriate Professional Liability insurance (min $20M cover) to practice in Australia?*
- Yes, I can provide a Certificate of Currency upon request
- No, but willing to obtain the required Insurance & provide Certificate of Currency
- Why do I need that?
Do you have an active Australian ABN/ACN?*
- Yes
- No
- why do I need one?
Australian Business Number / Australian Company Number
Which Modalities are you Currently Registered or licenced to practice?
Please provide registration numbers & details (+ URL links if appropriate).
Have you ever been de-registered, been sued for malpractice, had a liability claim, been prevented from practicing for any reason, or asked to leave a practice for any reason?*
- No
- Yes
(please provide more information if applicable below)
Is there any additional information you would like to provide?
i.e - any personal health considerations which may impact hours of practice. Any legal or other considerations.
Therapeutic Category
Years of practicing Experience?*
- 0 - 12 mths - recently fully registered practitioner
- 2 - 4 years
- 5 - 7 years
- 8-10 years
- 10+ years
Not including pre-registration or pre-licence practice or placement (only include time since full registration obtained).
Do you intend to practice Online or In-Person
- Online Only
- In-Person only
- Both Online & In-Person
- In-person (Multiple Locations)
If physical location or multiple locations please provide primary physical office location below or note 'home office' if working from home.
Primary office address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

(or note "home office" if same as residential)
Consent
Privacy & acknowledgement*
As part of consideration for Insight vs Instinct to support and advocate for you with clients, and also ethically market your services effectively, we will need to collect, record & retain certain personal information relevant to your current practice and history. You may view and/or request a copy of this information at any stage (an administrative fee may be incurred). All such information will remain highly confidential and will not be released without written consent or permission except where it is subpoenaed by a court or required by law.

I understand that completing this form is for information provision only & does not guarantee that Insight vs Instinct is obligated to assist in any way.

I agree that all questions have been answered fully, truthfully and to the best of my knowledge.

If I have further queries I will contact [email protected]
I agree to the privacy policy.
Feedback
I understand that feedback provided may be posted online or on our website, and can make a request, without bias or guarantees, that it be removed at any time. Feedback is requested and monitored for quality and promotional purposes.
I understand and will provide feedback (positive or constructive) to Insight vs Instinct about any client concerns/compliments and consent to my clients being sent a feedback form for this purpose.
Issues which you can help clients with:
Please note all relevant issues which we can promote your services & abilities to assist clients.
Business, Career & Education
- Select All
- Confidence
- Self Esteem
- Motivation
- Achieving Goals
- Procrastination
- Self Sabotage
- Career Issues
- Interview Skills
- Nerves / Anxiety
- Public Speaking
- Concentration
- Exams / Tests
- Memory
- Imposter Syndrome
- Workplace bullying
- Workplace mediation / conflict resolution
Intimate / Family
- Select All
- Intimate Relationship
- Couples Counselling
- Other Relationships (work/family)
- DV Recovery (domestic violence)
- Narcissistic Abuse Recovery
- Sexual Issues
- Fertility / IVF
- Teens
- Children
- Conception
- Pregnancy
- Birth
Addictions
- Select All
- Other Addictions
- Food
- Drinking
- Smoking
- Drugs
- Gambling
- Gaming
- Pornography
- Social Media / Phone
- Compulsive Behaviour
- Compulsive Thoughts
Anxiety & Depression
- Select All
- Anxiety
- Stress
- Fears
- Phobias
- Panic Attacks
- Guilt or Shame
- Trouble Relaxing
- Hypervigilance
- Childhood Trauma
- Sleep Problems
- PTSD
Physical Issues & Weight
- Select All
- Eating Problems
- Food /Diet
- Weight Problems
- Anorexia
- Bulimia
- Exercise
- Pain Control
- Hearing
- Sight/Vision
- Mobility
- Skin Problems
- Hair Growth
- PCOS
- Fibromyalgia
Any other issues you would like us to promote your services to clients
Comments
This field is for validation purposes and should be left unchanged.

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NEW Practitioner Details

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Current Practice

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Issues which you can help clients with:

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