1

AUTHORISED MENTAL HEALTH PRACTITIONER (AMHP)

NOMINATION FORM FOR INITIAL TRAINING

Full Name (as per AHPRA)
Profession: / Registered Nurse
Psychologist
Occupational Therapist
Social Worker / ☐
☐
☐
☐
AHPRA Registration Number: or
AASW Registration Number (if applicable):
Current Position Title:
HE Number:
Date of Birth:
Heath Service/Organisation
Workplace:
Public☐Private ☐NGO☐Public/Private Partnership ☐
Workplace Address:
Workplace Telephone Number:
Workplace Email:
Alternate Contact Telephone Number:

I am requesting to attend the Chief Psychiatrist’s training to be eligible for authorisation as anAuthorised Mental Health Practitioner

Please read and indicate your agreement by ticking all boxes:

I am a mental health practitioner with at least 3 years’ experience in the management of people with a mental illness ☐

I have completed the training perquisites, (certificates (3) must be attached with this application).

-Clinicians Education Learning Package

-Referrers Education Learning package

-MHPOD

  1. Mental Health Histories and Mental State Examination
  2. Risk Assessment and Management Overview
  3. Strategies for working with people at risk of suicide
  4. Working with people who self-harm
  5. Supervision and self-care in mental health services

-Reviewed the Capacity Presentation for AMHP’s

-Read the AMHP Requirements and Expectations.

I am aware I will not be authorised to practice as an Authorised Mental Health Practitioner until my name is published in the Government Gazette

I have read and agree to adhere to the Guidelines for Authorised Mental Health Practitioners☐

______Date:

Applicant’s signature

This form must be signed by an approved Delegate (see Delegation List)

ApprovedDelegate (Name): ______

Signature______Date:

Dr Nathan Gibson

Chief Psychiatrist

Office of the Chief Psychiatrist

Level 1, ‘WorkZone

1 Nash Street

PERTH WA 6000

Dear Dr Gibson,

Authorised Mental Health Practitioner (AMHP)

I wish to nominate ______to undertake the training to be an AMHP.

He/She meets all of the criteria for nomination as per the ‘Nomination Process to become an Authorised Mental Health Practitioner’ document issued by your office.

The nomination is in the interest of the service in terms of meeting its needs and enhancing the quality of care provided to our consumers.

On behalf of the service I am prepared to support the nominee in the role of the AMHP in terms of their engagement in regular clinical supervision and continual professional development to maintain competency, once authorised.

I also undertake by checking the boxes below to notify you or your delegate should the nominee once authorised,

☐beno longer required to undertake face to face assessments with mental health patients or persons suspected of meeting the criteria for involuntary status

☐movefrom their current position to another position within the service

transfers or leaves this service

☐havetheir professional practice be subject to an investigation

☐ goon extended leave of more than 12 months (see AMHP Guidelines).

Thank you for considering this nomination.

Yours sincerely,

Name: ______

Signature: ______

Approved Delegate

AMHP Initial Training Application –September2017(CW)