IPPP Membership Application

New Member

1. Details for IPPP database:

Title: ProfDrMrMsMrsMissOther:

Given Names: Last Name:

Practice Address(s):

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

2. Personal and other details

Business Mobile: Business Fax:

Home Phone Number: Mobile Number:

Email: Date of birth:

Preferred mailing address for IPPP contact: HomeBusiness

3. Referees

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.

Referee's details:

Telephone W: ( )

Referee's details:

Telephone W: ( )

4. Curriculum Vitae

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.

5. Levels of Membership

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.

Membership Basic Requirements

1. Membership of the Institute will be restricted to persons who are registered to practice as psychologists by Psychology Board of Australia.
2. Members will be required to demonstrate a commitment to on-going professional development and education within the field of psychology.

A. Member (Full-time practice) shall be those members who:

1. Meet the basic requirements, and
2. Have a publicly identified professional consulting office, with a telephone number in their own name, and an appropriate standard of client facilities, which allows for the provision of psychological services within a secure and confidential environment
3. Obtain at least 75% of their total earned income for psychological services on a fee for service basis, and
4. Have been approved for membership by the Executive, and
5. Have paid the appropriate subscription.

B. Member (Part-time practice) shall be those members who:

1. Meet the basic requirements, and
2. Obtain less than 75% of their total earned income for psychological services on a fee for service basis, and
3. Have been approved for membership by the Executive, and
4. Have paid the appropriate subscription.

C. Associate Member shall be those members who:

1. Meet the basic requirements, and
2. Obtain their principal source of income from their employment as a Psychologist within a business or partnership which derives its income through the provision of psychological services on a fee for service basis, and
3. Have been approved for membership by the Executive, and
4. Have paid the appropriate subscription.

D. Student Member

1. Meet the basic requirements, and
2. Provide evidence of current enrolment as a student (i.e. student ID card)
3. Have been approved for membership by the Executive, and
4. Have paid the appropriate subscription.

E. Retired Member

1. Meet the basic requirements, and
2. Provide a letter stating they have retired from practice
3. Have been approved for membership by the Executive, and
4. Have paid the appropriate subscription.

F. Corporate Member

1. Meet the basic requirements, and
2. Provide evidence that they operate in an employment, partnership or sub-contracting relationship.
3. Have been approved for membership by the Executive, and
4. Have paid the appropriate subscription.

Please note: Only Members (Full-time practice) and Members (Part-time practice) of the Institute shall be eligible to vote at general meetings.

I wish to apply for the following level of membership with the IPPP:

6. Applicant's declaration

(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.

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. If elected as a Member, I will be bound by the Constitution of the IPPP (Copies of the above document is available on the IPPP website).
3. I understand that my title, full name and business details (as listed under the Business Details section) will appear in the IPPP Membership Directory on the IPPP website, and that these details may be released by the IPPP upon request, unless I indicate otherwise by writing to the Secretary of the IPPP
4. I understand that in response to a request from a psychologist registration board, the Society may, at its discretion, disclose information held about my qualifications, experience and practice as a psychologist.

Signature: Date:

7. Payment

Member Renewal Fees:

New Member Fees:

Membership Fee: $___ + New Member Processing Fee: $15 = TOTAL$___

(Membership Fee will be refunded in the event that the application is unsuccessful.)

checkedTransfer money into the IPPP cheque account. Date transferred:

HAVE YOU ... ?

1. Enclosed a copy of your current curriculum vitae?
2. Obtained two nominations?
3. Signed the Declaration section?
4. Indicated the appropriate level of membership?
5. Finalised your payment?

SEND A COMPLETED & SCANNED FORM TO ... secretary@psychologists.org.au OR POST TO:

Membership Secretary
Institute of Private Practising Psychologist Inc.
PO Box 138, KENT TOWN SA 5071