Balint ANZ Membership Application Form

Thank you for your interest in joining the Balint Society of Australia and New Zealand. Welcome!

This form will provide the board with some basic information about you to inform a decision about your application. Information is confidential to the Balint ANZ board.

Sometimes we like to meet potential new members before making a decision and in this case, we will contact you.

Membership fees

The 2022-23 annual membership fee is $AU 200 (for Australian and international residents) and $NZ 200 (for New Zealand residents).

If you join part-way through the year, the membership fee is reduced proportionately.

After your application has been approved by the board, you will receive an invoice for the amount due.

Contact details

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Country CodeArea CodePhone Number

Email

example@example.com

Professional information

What is your profession? (E.g. GP, psychiatrist, psychologist, counsellor, veterinarian, etc.)

What are your professional qualifications?

What is your current position?

What is your professional registration body? (E.g. AHPRA, MCNZ, AASW, etc.) If you do not have a professional registration body, please describe your circumstances.

What is your registration number with that professional registration body?

Are there any current restrictions on your registration with the professional registration body listed above?

YesNo

Please describe the current restrictions on your registration.

Are you a health professional undergraduate student? Note that this includes graduate programmes such as graduate medical programmes.

YesNo

What is the name of the institution where you study?

What is your expected year of graduation?

Balint experience

Please describe your interest in Balint group work, especially any experience in a Balint group.

Is there a current member of the Balint Society of Australia and New Zealand (preferably an Accredited Leader) who would be prepared to nominate you for membership of the BSANZ?

YesNo

Do you consent for the Balint Society of Australia and New Zealand to contact your nominee to seek a nomination if necessary?

YesNo

Please provide the nominee's name and email address

If no nominee is available, we might contact you after you submit your application to arrange an introductory meeting with a member of the society.

Are you interested in joining the Leadership Accreditation Pathway to become an Accredited Balint Leader?

YesNo

You can find further information about the Leadership Accreditation Pathway by clicking here.

Are you a member of any other Balint society? (E.g. American Balint Society, UK Balint Society, etc.)

YesNo

Please name the society.

Are you accredited as a Balint leader with any Balint society affiliated with the International Balint Federation (IBF)?

YesNo

Please name the society.

Undertakings

If elected to membership of the BSANZ, do you:

Undertake to maintain appropriate professional indemnity insurance (if relevant)?
Agree to maintain membership of your professional registration body and to notify the BSANZ immediately if your membership should end or if any restrictions or conditions are imposed on your registration?
Undertake to abide by the code of ethics of your profession?
Agree not to conduct yourself in any way which would bring the BSANZ into disrepute?
Agree not to state or suggest that you are authorised by the BSANZ to lead Balint groups until you enrol in the Leadership Accreditation Pathway or become an Accredited Leader?

If I am elected to membership of the Balint Society of Australia and New Zealand, I agree to abide by the undertakings above.

YesNo

It is a condition of membership of the Balint ANZ that you agree to these undertakings. Unfortunately, we will not able to accept your application until you agree with these undertakings.

If you would like to discuss this further, please contact admin@balintanz.org