1February 2018
Dear DCP members,
Re: Updating of the “List ofNon-government (Voluntary) Organizations
Providing Clinical Psychology Services” and
the “List of Registered Clinical Psychologistswith Independent or Private Practice”
Please be informed that DCP is going to update the captioned lists.As a service to the public, DCP provides the liststo the general public and public organizations upon request without charge. The lists are also available on DCP’s website for public access.
If you wish to list the information of your practice on the aforementioned lists, please kindly complete the attached form and return to us on or before 28.02.2018. You may refer to the current lists at the website of DCP for reference. Links as follow:
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For the List of Non-governmentOrganizations, only organizations with services provided by paid-up DCP members could be listed.Moreover, DCP will publish the names of the DCP members who are working for the organizations on the list if the member wishes to be listed. The DCP members concerned should sign on the attached form to signify their consent.
For the List of Registered Clinical Psychologists with Independent or Private Practice, only paid-upDCP members and Registered Clinical Psychologists of HKPS for the current yearwill be listed.
Should you have any queries, please feel free to contact us via e-mail k you for your attention.
Yours sincerely,
Nicola CHUNG
External Relations Officer,
Division of Clinical Psychology,
The Hong Kong Psychological Society Ltd.
DCP/ER/Update NGO form/01/2018
Update form: Non-Government (Voluntary) Organizations
providing Clinical Psychology Services
I have studied the “List of Non-government (Voluntary) Organizations
Providing Clinical Psychology Services”, and:
(Please take appropriate boxes)
Information of Clinical Psychology Service of myorganization on the current list is accurate and amendment is not needed.
Amendment to the information of Clinical Psychology Service of myorganizationon the current listis needed (please provide information which needs to be changed in the form on the next page).
Information of Clinical Psychology Service of myorganization is provided in the form on the next page (For members who have never been added on the list).
I declare that the information provided to DCP herewith is true to the best of my knowledge and belief.
Director of the Organization: ______
Signed: ______
Date: ______
Please tick all relevant parts and fill in all relevant blanks. Ticking more than one box is acceptable.
Part I: Organization information
English Name : ______
Name in Chinese, if applicable :______
Organization address in English
Organization address in Chinese (please print/scan your name card):
Organization Telephone No.: ______Fax No.:______
Webpage (if any): ______
Information aboutthe Clinical Psychologists working in the organization:
Name / DCP members? / Member’s consent**By signing his/ her name in this column, the member is giving DCP the consent to publish his/ her name under the organization on the List of NGOs.
Part II: Service Provided
Service Target (please specify the districts your organization serves):
(English) ______
______
(Chinese) ______
______
Types of Service:
[ ] Individual session[ ] Group counseling[ ] Family therapy
[ ] Rehabilitative service[ ] Others, please specify: ______
Referral Arrangements:
[ ] Accept referral from social worker / counselor of own agency only
[ ] Accepts referral from social worker / counselor of other agencies
[ ] Accepts self referral
Service Charges:
[ ] Free[ ] Sliding scale according to income
[ ] Private rate[ ] Others, please specify: ______
I request to have the above information listed in the:
[ ] English version
[ ] Chinese version
DCP/ER/Update Indept form/01/2018
Update form: DCP Members with Independent or Private Practice
I have studied the “List of Registered Clinical Psychologists with Independent or Private Practice”, and :
(Please take appropriate boxes)
1. I work on an independent basis in the year ______:
Information of my practice on the current list is accurate and amendment is not needed.
Amendment to the information of my practice on the current listis needed (please provide information which needs to be changed in the form on the next page).
Information of my practice is providedin the form on next page (For members who have never been added on the list).
2. I no longer work on an independent basis. Please remove my name from the
list.
I declare that the information provided to DCP herewith is true to the best of my knowledge and belief.
Name: ______Signed: ______
Date: ______
DCP/ER/Update Indept form/01/2018
Update List of DCP Members with Independent or Private Practice
Please tick all relevant parts that amendment to your information is needed.
For the part that amendment is needed, please circle the relevant item(s) marked with *, tick all relevant [ ] & fill in all relevant blanks.
Part I: (print/scan your name card)
English Name (surname first): ______(Ms/Mrs./Mr./Ph.D/PsyD.*)
Name in Chinese, if applicable (surname first): ______(女士/太太/先生/博士)*
Office name & address in English
Office name & address in Chinese (print your name card):
Office Telephone No.: ______Office Fax No.: ______
Webpage (if any): ______
Part II: Professional Information
Academic qualifications relevant to CP practice (Master & above, e.g. HKU(1990)-M.Soc.Sc(CP)):
______
HKPS Membership Status: Graduate/Associate Fellow/Fellow*;
HKPS Registered Psychologist (RP) status: [ ] RP(CP); [ ] RP (no affiliation);[ ]RP(other:______)
Paid-up DCP Member (as at Apr 2018): Yes/No*
Part III: Service Provided
Mode of Private Practice:
[ ] On an individual basis (with an individual business registration): ______
[ ] Practising as an employee on commission
Languages and dialects spoken with sufficient proficiency in clinical practice:
[ ] Chinese: Cantonese/ Putonghua/ Other dialects (specify): ______
[ ] English; [ ] Other languages: ______
Clientele:[ ] Child; [ ] Adolescent; [ ] Adult; [ ] Older Adult; [ ] Couple; [ ] Family
Areas of service:
[ ] Assessment; [ ] Professional consultation/supervision to practitioners/organizations;
[ ] Treatment; [ ] Forensic;[ ] Others (specify): ______
Referral Arrangements (by appointment on phone):
[ ] Self; [ ] Referrals from other professionals/school accepted.
I request to have the above information listed in the:
[ ] English version
[ ] Chinese version
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