New Client Form and Consent

First Name *

Last Name *

Preferred Name (if applicable)

DOB *

Phone Number *

Email Address *

Home Address *

Suburb *

State *

Postcode *

Medicare Card

Medicare Number *

Position on Medicare Card

Expiry

Is there an alternative Medicare claimant such as a parent?For example, will a Medicare rebate be directed to a parent's bank account? If so, please specify the claimant's Medicare details.

Full Name Of Medicare Claimant (e.g. parent)

Mobile Number of Claimant

DOB of Claimant

Medicare Number of Claimant

Position on Medicare Card of Claimant

Next of Kin Contact Information (e.g parent or partner)

Name *

Mobile Phone *

Relationship to you *

We are committed to inclusive and respectful practice. We invite you to share cultural, religious, or other aspects of your identity or background that would help us provide you with care. (optional)

Confidentiality and Privacy

We are committed to protecting confidentiality and adhere to standards in line with the Psychology Board of Australia. Personal information gathered during the provision of the psychological services will remain confidential in most circumstances, except:

If it is subpoenaed by a court or otherwise legally required
Failure to disclose the information would place you or another person at risk
Where you have given approval to obtain or disclose information.

By submitting this form you authorise your psychologist to:

Acquire information from relevant doctors and other parties.
Provide a letter summarising your treatment to your referring doctor (if applicable).
Discuss your care with a senior psychologist colleague and in a confidential internal case review.

Your personal information will be saved in our secure systems for a minimum of 7 years.

Fees

Your service may be eligible for funding from Medicare, NDIS, Workcover, TAC or private health insurance. If attending with a GP referral under Medicare, a standard 50 minute consultation will usually have an out of pocket expense of approximately $156.

The following terms apply:

Medicare card holders with a Mental Health Care Plan are entitled to a rebate for up to 10 sessions per calendar year. Fees range from $255 to $280 and Medicare rebates range from $98.95 to $145.25. The costs for psychological assessments are provided separately.
If not claiming via Medicare, sessions can be claimed via Private Health Extras Cover. Rebates vary according to your level of cover so please contact your insurer for details.
Appointment times with high demand (from 4pm) attract a $20 premium.

Cancelled appointments

We require 48 hours notice to reschedule or cancel a session. In the event that fewer than 48 hours notice is given to cancel an appointment, a $100 appointment fee will be charged.

Health Information

Your psychologist may use an AI Scribe to help automate aspects of note-taking and documentation. Audio is converted into clinical notes, and is not retained. Data is not used to train AI models.

We may request for you to fill in questionnaires about your symptoms or your experience of our service. Anonymous data may be used for quality improvement and research purposes.

I agree (optional)

Consent

Please let your psychologist or admin staff know if you have any questions about the contents of this form. We are happy to discuss this with you. When submitting this form, we will rely on this consent to the above terms during your engagement with our service. You may withdraw your consent at any time.

Please confirm you have read and agree to terms *