Independent Contractor Registration – Australian DBT Institute

The Australian DBT Institute provides a collegial space for independently contracted mental health practitioners to practice from our three private mental health clinics and through DBT Assist (our National DBT Telehealth Service).

Before commencing with one of our Essentia Health Clinics or DBT Assist, each independently contracting mental health practitioners is required to:

Complete and upload the independent mental health practitioner contractor agreement
Complete the below registration form
Agree to maintain professional development, supervision, and registration requirements of their profession

Please complete the below form and attach all required documentation before commencing with Essentia Health Clinics or DBT Assist. Should you seek clarification about the below form please contact our admin team at the Australian DBT Institute via email at info@dbtinstitute.com.au

Personal Information

Name *

First

Last

Email *

Mobile Phone (private - we will not share with clients) *

Mobile Phone (to share with individual clients)

If you have a seperate number for clients to contact you please provide this number. We do not expect clinicians to have a seperate number nor do we expect you to have a direct line for clients to contact you. Please state NO PHONE NUMBER TO SHARE if you do not wish to share any phone numbers with individual clients!

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Next of Kin (incl. phone number)

We hope we never need to use this. In the case of an emergency our clinical director or executive director will contact your NOK if needed.

Your Banking Details

Please include your Account Name, Bank, BSB and Account Number

Clinical Practice

Please indicate which DBT Institute Locations you will be practicing from.

Essentia Health (Gold Coast, Queensland)
Essentia Health (Brighton, Victoria)
Essentia Health (Sydney, NSW)
Sunshine Coast Hinterland (DBT Retreats)
DBT Assist (Telehealth)

Year of first registration for the above profession

Qualifications

Please provide the qualifiction and any abbreviations used when communicating qualifications

Professional Profile

Profile photo

Click or drag a file to this area to upload.

Please provide a professional looking photo for promotion on our website

Professional Memberships

Availability

Please list the day(s) of the week and times you plan to be working in our clinical services (Essentia and/or DBT Assist)

Professional Profile

Limit of 300 words - Please provide a brief summary of your clinical practice and areas of interest.

Supporting Information

Professional Registration Identifier

Number provided on your certificate of registration

Professional indemnity insurance policy number

Australian Business Number (ABN)

Practicing Certificate/Professional Registration(s)

Click or drag files to this area to upload. You can upload up to 3 files.

Certificate of Currency

Click or drag a file to this area to upload.

Please upload your Certificate of Currency for your professional indemnity insurance

CV/Resume

Click or drag a file to this area to upload.

Independent Contractor Agreement *

Click or drag a file to this area to upload.

This agreement needs to be signed and can be downloaded at http://dbtinstitute.com.au/wp-content/uploads/2022/01/Independent-Contractor-Agreement.pdf

Any further information

Australian DBT Institute

Phone Number

Contact Address

Email Address

Personal Information

Clinical Practice

Professional Profile

Supporting Information