TELUS HEALTH AUSTRALIA AFFILIATE APPLICATION

  • TELUS HEALTH

    AUSTRALIA AFFILIATE APPLICATION

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    OUR CORPORATE REQUIREMENTS TO BECOME AN AFFILIATE PROVIDER IN OUR AUSTRALIA NETWORK INCLUDE*

    • ACA Level 3 and above or PACFA registered clinician registered with Master of Counselling (for counsellors)
    • AASW or AHPRA registered (for social workers, and psychologists)
    • Minimum 3+ years of post- registration experience
    • Public liability and professional indemnity insurance (minimum requirements = Public Liability 2M per claim, 10M in aggregate; Professional Indemnity 2M per claim, 6M in aggregate)
  • DO YOU MEET THE CORPORATE REQUIREMENTS OUTLINED ABOVE?*

  • PRACTICE INFORMATION

  • ABN ENTITY TYPE:
  • TYPE OF PRACTICE:

  • PRIMARY PRACTICE

  • PRIMARY PRACTICE TYPE:
  • AREA:
  • WHEELCHAIR ACCESSIBLE?
  • PUBLIC TRANSPORT ACCESSIBLE?

  • DEMOGRAPHIC INFORMATION

  • Would you like to receive referrals by Text Email

  • EDUCATION DETAILS

  • PROFESSIONAL REGISTRATION WITH RELEVANT HEALTH BODY

  • CLINICAL INFORMATION

  • How many years of experience do you have conducting Bio/Psycho/Social Assessments, short-term solution focused counselling, assisting with work/life issues that impact job performance and connecting clients to resources and long-term care?
     *   

  • How many years of post-graduate direct clinical experience do you have? *   

  • Which Services are you interested in providing?*

  • PROVIDER CHARACTERISTICS

  • MODALITIES*
  • CLIENTELE SERVED*
  • PRESENTING ISSUES YOU ARE COMFORTABLE WORKING WITH, CHECK ALL THAT APPLY*

  • TELEHEALTH PREFERRED PROVIDER AVAILABILITY FORM

    Please fill out the information below for TELUS's calendar. Please note this can be adjusted in future at any time.
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  • ATTESTATION STATEMENT

  • All information submitted by me in this application, as well as any attachments or supplemental information, is true, current, and complete to the best of my knowledge and belief as of the date of the signature below. I fully understand that any information provided during the application or recredentialing process is subject to TELUS Health investigation and review. I understand that if any information contained in this application is determined to be false or constitutes a material misstatement, my application may be denied or my affiliate status may be terminated by TELUS Health immediately. I further understand that in that event, TELUS Health may be required to submit a report to state licensing authorities. By signing this form, I certify that all of my answers are complete, true, and correct.

  • Date*
     - -

  • APPENDIX

    APPENDIX OFFICE SPACE CHECK LIST

  • PROFESSIONAL BUSINESS OFFICE:

     

    Exterior of the Counselling Office Checklist:

    The entrance to the building and building number are well lit, clearly marked and visible to clients. 

     

    Interior of the Counselling Office Checklist:

    ·       There is designated professional waiting area.  

    ·       This setting maintains a professional standard of cleanliness and privacy.

    ·       The office is soundproofed.

    ·       A high level executive would feel comfortable in the waiting room and office space.

    ·       Restrooms are clearly marked, easily accessible to all clients and they maintain standards of cleanliness and privacy.

     

    HOME OFFICE*: 

    *Approval is required for home offices. Four photographs are required: front entrance, walkway to office (from entrance way to office), office and view from office window.

    ·       The street number is clearly visible to the client.

    ·       There is a separate entrance for clients. 

    o   If not, there is a boundary between the home life and the office life (ie. No pets or children in the office area, rest of the house not visible to clients, etc.)

    ·       The office has a professional waiting area with professional standard of cleanliness and privacy.

    o   If not, I set appointment 15-30 minutes apart.

    ·       The office is soundproofed to ensure confidentiality.

    ·       A high level executive would feel comfortable in the waiting room and office space. 

     

    WHEELCHAIR ACCESSIBILITY:

    Counsellor’s office must meet the following criteria in order to be deemed wheelchair accessible. 

     

    Exterior of Counselling Office: 

    ·       The surface is firm and slip resistant, free from obstruction, and free from small units such as gravel and cobblestone.

    ·       There are ramps to the building alongside steps or at clearly marked locations to access the building in a wheelchair.

    ·       The door’s width is adequate for wheelchairs. (32 to 36 inches) 

     

     If applicable:

    ·       The two-door entrance has a vestibule between the doors that is a minimum of 48 inches long and 60 inches wide. 

    ·       The after hours doorbell or intercom is operable by one hand and between 32 and 48 inches from the ground.

    ·       The automatic door opener is operable by one hand and between 32 and 48 inches from the ground. 

     

    Interior of the Counselling Office: 

    ·       The counseling office ensures that doorways are accessible to wheelchairs. (32 to 36 inches)

    ·       All controls and elevators are accessible to wheelchairs and operable by one hand.

    ·       Hallways are a minimum of 48 inches wide.

    ·       There is at least one toilet stall that is barrier free and accessible by wheelchair users. 

     

    Wheelchair parking:

    ·       There is at least one clearly marked wheelchair parking spot in close proximity to a barrier free entrance way.

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