Form 5 - Brisbane MIND: Change to Approved Clinician List

Form 5 - Brisbane MIND: Change to Approved Clinician List

Contractor Details
Entity Name (the legal entity which holds the Brisbane MIND contract with the PHN)
Business/Practice Name (trading name)
Name of Contractor Representative
Position
Email address
Mobile phone number
Clinician is: / Withdrawing from the Brisbane MIND program (See Section 1 below)
Seeking approval to provide services under the Brisbane MIND program (See Section 2 below)

Section 1: Clinician is withdrawing from Brisbane MIND program

Clinician name / Date from which clinician intends to withdraw

Current Client List

Client Name / DOB / Number of sessions utilised on current purchase order* / Will this client transition to a new clinician within the practice?** / Name of new clinician
Yes
No (Date of last session)______
Yes
No (Date of last session)______
Yes
No (Date of last session)______
Yes
No (Date of last session)______
Yes
No (Date of last session)______
Yes
No (Date of last session)______
Yes
No (Date of last session)______

*Please note that all utilised sessions are required to be invoiced before a client can be transitioned to a new clinician.
**If the client requires to be transitioned to a clinician outside of your practice please indicate the date of their last session.

Section 2: Clinician seeking approval to provide services under Brisbane MIND

Clinicians
Referrers (i.e. GPs) have access to the Brisbane MIND Provider Directory, a database listing all clinicians currently contracted to deliver Brisbane MIND services. Mobile phone numbers will not be published on this Directory without permission.
Contractor Representatives are able to nominate any suitable clinician who is currently employed or subcontracted by the Contracting Entity. Contractor Representatives are responsible for ensuring clinicians meet the following requirements:
·  hold current registration as a Psychologist, Accredited Mental Health Social Worker, Accredited Mental Health Nurse, Mental Health Occupational Therapist, or Aboriginal and Torres Strait Islander Health Worker; and
·  have no conditions upon their professional registration/membership; and
·  act in accordance with industry standards and best practice requirements when delivering services; and
·  hold Public Liability insurance for an amount of no less than $10 million per claim; and
·  hold Professional indemnity insurance (inc. medical malpractice insurance) for an amount of no less than $10 million per claim; and
·  have a current National Crime Check in place.
Clinician Contact Details
Name
Type of Profession
Registration Number*
Email address
Mobile phone number

* Social Workers, Mental Health Nurses and Occupational Therapists must provide evidence of their registration.

Service Delivery Location/s
Service Delivery Location / Days of Work
Areas of Specialisation
Brisbane MIND requires an indication of key areas of expertise for all clinicians. This information will be made available to referrers and used to support appropriate referral pathways.
Languages spoken other than English
In each of the lists below, please tick the column that applies to the clinicians level of specialisation
Please indicate level of specialisation to work with the following clinical presentations
Unable/Not interested / Limited training and experience / Professionally competent / Specialist area of expertise
Mood Disorders
Anxiety Disorders
Somatoform Disorders
Borderline Personality Disorder
Post-Traumatic Stress Disorder
Complex Post-Traumatic Stress Disorder
Substance-related and addictive disorders
Hoarding and squalor
Eating Disorders
Personality Disorders
Postnatal Depression
Pain Management
Chronic health conditions
Please indicate level of specialisation to work for the following therapeutic approaches
Unable/Not interested / Limited training and experience / Professionally competent / Specialist area of expertise
Cognitive-Behavioural Therapy (CBT)
Acceptance and Commitment Therapy (ACT)
Dialectical Behavioural Therapy (DBT)
Interpersonal Therapy (IPT)
Family therapy
Mindfulness-Based Cognitive-Behavioural Therapy (MCBT)
Solution-focused brief therapy
Eye Movement Desensitisation and Reprocessing (EMDR)
Schema focused therapy
Trauma Informed Care and Practice
Please indicate level of specialisation to work with the following population groups
Unable/Not interested / Limited training and experience / Professionally competent / Specialist area of expertise
People experiencing financial disadvantage
Homeless or vulnerably housed people
Aboriginal and Torres Strait Islander people
Culturally and linguistically diverse people
People who have experienced trauma and/or abuse
People at risk of suicide
Lesbian, Gay, Bisexual, Transgender, Intersex and Queer (LGBTIQ) individuals
People involved with the criminal justice system
Young people (12-25 years)
Adults (25-65 years)
Older adults (65 years +)