New Client Form and Consent

Details of Child or Young Person

First Name *

Last Name *

Preferred Name (if applicable)

DOB *

Street Address *

Suburb *

State *

Postcode *

Medicare Number *

Position on Medicare Card

Expiry

First Parent / Guardian Details

Full Name *

DOB *

Mobile Phone *

Relationship with Child *

Email Address *

Medicare Number

Position on Medicare Card

Home Address *

same as child

Home Address *

Second Parent / Guardian Details

Full Name

Relationship with the Child

Mobile Phone

Email Address

Home Address

same as child

Home Address

Please answer the following questions in relation to the child

Describe the child's living arrangements. ie: who does the child live with? *

Are all parents and other legal guardians / custodians of the child aware that input from a psychologist is being sought? *

Please provide details *

Are there any court proceedings or orders related to the family or child? *eg. custody or IVO

Please provide details *

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 your child 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 health providers, school, family members or other parties involved in your child's care.
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.

We aim to balance your child's privacy with your role as their parent / guardian. Your psychologist will discuss with you which aspects of your child's information may be shared with you, and the type of conversations that may be kept private to support therapeutic engagement.

Your child's 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.

Name of person completing this Form *

Please confirm you have read and agree to terms *