Given Names: Last Name:
PBA Endorsed Areas of Practice (if applicable): ClinicalCommunityCounsellingForensicHealthNeuropsychologyOrganisationalSports & ExerciseEducational & Developmental
The above details may be published on the IPPP website's publicly searchable database: YesNo
Business Mobile: Business Fax:
Home Phone Number: Mobile Number:
Email: Date of birth:
Preferred mailing address for IPPP contact: HomeBusiness
As part of the Member application process, all applicants need to submit declarations by two health professionals who are registered with AHPRA (the Australian Health Practitioner Regulation Agency), with at least one of those being a Psychologist (and, preferably, a Member of the Institute of Private Practising Psychologist Inc.) when applying to become a Member/Associate Member.
Telephone W: ( )
Please attach current curriculum vitae detailing qualifications (and details of supervised experience towards registration, if relevant), current and past employment, employers, duration, and responsibilities in the practise of Psychology.
Please read the following information on the levels of Membership with the IPPP [Member (Full-time practice), Member (Part-time practice), or Associate Member] and indicate by ticking the relevant box below of level of membership for which you wish to apply.
A. Member (Full-time practice) shall be those members who:
B. Member (Part-time practice) shall be those members who:
C. Associate Member shall be those members who:
D. Student Member
E. Retired Member
F. Corporate Member
Please note: Only Members (Full-time practice) and Members (Part-time practice) of the Institute shall be eligible to vote at general meetings.
(a) Have you been or are you currently under investigation by any disciplinary or legal tribunal? YesNo
(b) Have charges of unprofessional conduct ever been brought against you? YesNo
(c) Have you been convicted in the past 10 years of an offence involving a criminal charge, or are there any charges pending? YesNo
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 Committee. In evaluating your application, the IPPP Executive Committee 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 on its merits.
(Membership Fee will be refunded in the event that the application is unsuccessful.)
checkedTransfer money into the IPPP cheque account. Date transferred:
Membership SecretaryInstitute of Private Practising Psychologist Inc.PO Box 138, KENT TOWN SA 5071