Form VI : See rule 11(1)
Protection Of Women From Domestic Violence Rules 2006
Form VI :
[See rule 11(1)]
Form For Registration As Service Providers Under Section 10(1) Of The Protection Of Women From Domestic Violence Act, 2005 (43 Of 2005)
1. Name of the applicant
2. Address alongwith phone number, e-mail address, if any
3. Services being rendered :
Shelter
Psychiatric counselling
Family counselling
Vocational Training Centre
Medical Assistance
Awareness Programme
Counselling for a group of people who are victims of domestic violence and family disputes
Any other, specify
4. Number of persons employed for providing such services
5. Whether providing the required services in your institution requires certain statutory minimum professional qualification? If yes, please specify and give details
6. Whether list of names of the persons and the capacity in which they are working and their professional qualification is attached?
Yes
No
7. Period for which the services are being rendered
3 years
4 years
5 years
6 years
More than 6 years
8. Whether registered under any law / regulation
Yes
No
If yes, give the registration Number
9. Whether requirements prescribed by any regulatory body or law fulfilled?
If yes, the name and address of the regulatory body
Note :
In case of a shelter home, details under columns 10 to 18 are to be entered by registering authority after inspection of the shelter home.
10. Whether there is adequate space in the shelter home
Yes
No
11. Measured area of the entire premise
12. Number of rooms
13. Area of the rooms
14. Details of security arrangements available
15. Whether a record available for maintaining a functional telephone connection for the use of inmates for the last 3 years
16. Distance of the nearest dispensary/clinic/medical facility
17. Whether any arrangement for regular visits by a medical professional has been made?
Yes
No
If yes, name of the
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Medical Professional
Address
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Contract number
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Qualification
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Specialisation
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18. Any other facilities available, specify
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Note :
In case of a counselling centre, details under columns 19 to 25 are to be entered after inspection by registering authority.
19. Number of Counsellors in the centre
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..........................
20. Minimum qualification of the Counsellors, specify
Under graduate
Graduate
Post graduate
Diploma holder
Professional degree
Any other, specify
21. Experience of the Counsellors
Less than a year
1 year
2 years
3 years
More than 3 years
22. Professional qualification/experience of Counsellors
Professional degree
Experience in family counselling as a ........................(designation) in the ....................(Name of the organisation)
Experience in psychiatric counselling as .....................(designation) in the ....................(Name of the organisation)
Any other relevant experience, please specify
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23. Whether a list of names of Counsellors alongwith their qualifications has been annexed
Yes
No
24(a). Type of counselling provided
Supportive one-to-one counselling
Cognitive behaviourable therapy (CBT) (Mental process that people use to remember, reason, understand, solve problems and judge things)
Providing counselling to a group of people suffering
Family counselling
24(b). Facilities provided
Offering personal professional and confidential counselling sessions
A safe environment to discuss problems and express emotions
Information on counselling services, support groups and mental health care resources
One-to-one counselling and group work
Therapies, ongoing counselling and health related support
Any other, please specify
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24(c). Any other service
(1) Services being provided
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(2) Personnel appointed
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(3) Statutory minimum qualifications required for providing such service
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(4) Whether a list of names of personnel engaged for providing service alongwith their professional qualification is annexed
Yes
No
(5) Any other details which the service provider desirous of registration may provide
..................If necessary continue on a separate sheet.
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Place ..........................
Date ...........................
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Signature of authorised official
Designation.
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