Application toBlue Knot General Practitioner Referral Database.

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Personal Details

Title

Last Name

First Name

Gender

This information will be used by Blue Knot Foundation to contact you:

Email

Phone Number

Mobile Phone

Address

City

State

Post Code

Where did you find out about applying for the Blue Knot Referral Database?

Please specify

Practice details

This information will be provided to Blue Knot Helpline and Redress Support Service clients when your name is provided for a possible referral:

Practice Name

Phone number

Email

Alternate phone number

Address

City

State

Post Code

Website

Do you provide your service online that can be accessed by anyone in Australia?

Professional Details - Memberships & Affiliations

Current clinical memberships or affiliations

General Practitioners on the Blue Knot Referral Database must hold a membership with Australian Health Practitioner Regulation Agency (AHPRA). Please enter the details of this membership below.

Please provide this information in the following format for each applicable association: Professional body, Membership Number, Year joined, Certification Document

If you hold any other listed current unrestricted practicing certificate with an eligible Australian professional body at the level of full membership (Royal Australian College of General Practitioners (RACGP), Australian College of Rural and Remote Medicine (ACRRM), Australian Society of Psychological Medicine (Member or Fellowship)) please select add another membership below and fill in the relevant details. Please do not include any certifications where the membership status is intern, associate, provisional clinical, affiliate, student or similar.

Please provide this information in the following format for each applicable professional body: Professional body, Year joined, Certification Document

Professional body

Year Joined

Valid To

AHPRA Registration Number

Certification document Upload

Knowledge of trauma-specific therapy

General practitioners applying for listing on the Blue Knot Referral Database need to demonstrate an understanding of the needs and presentations of patients with experience of complex childhood trauma as opposed to 'single incident' trauma, as well as the principles of trauma-informed practice. The Blue Knot website has a large number of resources suitable for GPs including its Talking about Trauma publication for Primary Health Care Practitioners which can be downloaded or purchased here: https://professionals.blueknot.org.au/resources/publications/talking-about-trauma-series/

General trauma-informed approach

Describe the way you work integrating trauma-informed principles into your daily practice. Explain specifically how you engage with patients in a way which identifies possible complex trauma presentations, and how you work to foster healing and minimise the risk of retraumatisation. (Maximum 500 words)

Programs referred to or collaborated with
Describe the way you support your patients with complex childhood trauma histories including decisions around referral for ongoing therapeutic care, as well as who you refer to and how you coordinate ongoing care and support.

Further information

Is there anything else you would like to tell us that is relevant to your application for inclusion on the Blue Knot Referral Database? (Maximum 300 words)

Fees and Benefits Schemes

What is your fee for a standard consultation - in dollars?

Do you bulk bill?

All patientsConcession card holders onlySome patients, by agreement

Are you registered for any benefit schemes?

MedicareVeterans AffairsOther (please specify)

Other Benefit Schemes

Declaration

Please review the following information carefully.

I understand that Blue Knot Foundation reserves the right to solely make decisions about all listings on the Blue Knot Referral Database, including but not limited to additions to, renewals and removals of listings from it.

I understand that Blue Knot Foundation will require me to receive ongoing trauma-informed supervision and also provide an annual update of my registrations and memberships including current AHPRA practicing Certificate of Registration.

I understand that a listing on the Blue Knot Referral Database does not guarantee how often my details may be provided to Blue Knot Helpline clients, nor how often I may be contacted with an enquiry about my services.

I understand that Blue Knot Helpline and Redress Support Service counsellors have limited engagement with callers and are only able to undertake basic needs assessment and that it is solely my responsibility to assess the suitability of every referral made to me.

I confirm that I will advise the Blue Knot Helpline and Redress Support Services in via email to referraldatabase@blueknot.org.au if:

My contact details change
I no longer hold a practicing AHPRA registration
Any other practice-related matters change

I understand that the Blue Knot Foundation is not able to investigate or determine any complaints made by a patient against me and that patients will be referred by Blue Knot Foundation to the relevant complaints body for such purposes.

I confirm that I will advise Blue Knot Foundation in writing if:

Any professional body with which I am registered, or a relevant complaints body commences an investigation related to a patient complaint
My practice is restricted by an accrediting body
My membership of any accrediting body is cancelled

I understand that Blue Knot Foundation will suspend the listing of a General Practitioner from the Blue Knot Foundation Referral database under any of the above circumstances, and also if Blue Knot Foundation is notified in writing that a complaint against a practitioner listed on the Referral Database has been submitted to a relevant complaints body. When the General Practitioner's registration is fully reinstated and/or a complaint is finalised with no impact to their registration, the General Practitioner can advise the Helpline Program Coordinator on referraldatabase@blueknot.org.au and request their listing be reactivated on the Referral database.

I confirm that any referrals I accept will be as an independent practitioner and not as an employee, agent or sub-contractor to Blue Knot Foundation. I acknowledge that apart from maintaining the Referral database, Blue Knot Foundation has no role in or responsibility for the referral process or any subsequent treatment provided and receives no financial benefit from the referral.

I,

confirm I have reviewed and understood all the information included in this application,

YesNo

confirm that the information I have provided is true and accurate.

YesNo

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