Please complete all the required fields below Name * First Name First Name Last Name Last Name Phone * Email * ACC Provider ID Please enter your ACC Provider ID if you have one Profession * Psychiatrist Psychologist Neuropsychologist Psychotherapist Counsellor Social Worker Counsellor/Social Worker Arts Therapist ADHD Coach Contract Services * Please select the Contract(s) you can provide services for ISSC - Integrated Services for Sensitive Claims PSA - Psychological Services (psychologists only) NASA - Neuropsychological Assessment Services CPSA - Clinical Psychiatric Services IMPA - Impairment Assessment Services PVT - Private Pay Services Location * Please advise the location(s) you are able to provide services in APC * Do you hold a current annual practicing certificate (APC) Yes No Indemnity Insurance * Do you hold current indemnity insurance? Yes No Fully Vaccinated * Our practice is mandated by the COVID-19 Public Health Response (Vaccinations) Order 2021. Are you fully vaccinated? Yes No Additional Information CV * Files must be less than 2 MB.Allowed file types: pdf doc docx.
