Application toBlue Knot Agency Referral Database.

Overview of Services Offered

Service or Agency Name

Please select the geographic scope of your service

NationwideState Specific

Are you a DRC Funded Agency?

YesNo

Are you applying for:

The whole of your organisation to be approved for our database, orSpecific components or services that your organisation offers (please specify)

Please provide a brief description of these services and how they are

tailored to the specific needs of survivors.

Do you provide services to groups?

Yes

No

Please list groups offered:

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

Other, please specify

Service Contact Details

Phone: (Number to be given to callers, including area code):

Alternative Phone Number (optional):

Alternative phone number

can be given out to callersis only for Blue Knot Foundation to contact us

Service Address: (This address will be given out to callers)

City

State

Post Code

Does your service provide services in languages other than English? If so,

please select from list below (press CTRL to select multiple languages).

Additional information (optional)

Email Addresses

for clients to contact you

for Blue Knot Foundation use only

Website(s) for your service or agency (optional)

Do you have an Alternate Postal Address to which Blue Knot Foundation can send correspondence: (This would not be given to callers)

YesNo

Address

City

State

Post Code

Page 4

Understanding and Responding to
Clients with Complex Trauma Histories

Please describe the qualifications and competencies you use to

recruit staff with trauma-specific skills suitable for working with adult survivors.

Please outline your agency’s requirements with regards to external

accreditation of clinical staff. Do all clinical staff hold a current practicing

certificate with an eligible Australian professional body (e.g. PACFA, APS,

RANZAP, AASW, ACA)?

Please describe the ongoing training and supervision provided to or

obtained by your staff specific to working with clients with complex trauma experiences, and if these are provided in-house. Are all supervisors trauma-informed?

How do you monitor and evaluate service provision to ensure that this is

adequately meeting the specific needs of adult survivors of childhood

trauma and abuse?

Blue Knot Foundation has published a series of Guidelines around trauma-informed practice and the clinical treatment of complex trauma clients. These guidelines are available to purchase in soft or hard copy formats from https://professionals.blueknot.org.au/resources/publications/

Please confirm if your service has accessed these guidelines?

YesNo

Blue Knot Foundation promotes five key trauma-informed principles in these guidelines. Please outline the way your service or agency embeds each of these principles.

Principles Response (500 words)

Please describe how your service or agency is inclusive of all forms of diversity. (300 words)

Is there anything else you would like to tell us about your service or agency
that is relevant to this application?

Contact details of the Person

Completing this Application

Primary Contact Person

First name

Last name

Email

Phone

Alternate Contact Person

First name

Last name

Email

Phone

Conditions for Listing & Disclaimers

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 a listing on the Blue Knot Referral Database does not guarantee

how often referrals may be provided to Blue Knot Helpline and Redress Support Service clients, nor how often an agency may be contacted with an enquiry for service provision.

I understand that Blue Knot counsellors have limited engagement and are only able to undertake basic assessment of a their particular needs and that it is solely the agency’s responsibility to assess the suitability of every referral made to them.

I understand that the Blue Knot Foundation is not able to investigate or determine any complaints made by a client against any agency or service provider within an agency and that clients will be referred by Blue Knot Foundation to the relevant complaints body for such purposes.

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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