Select who will be the client (select BOTH a & b if parent & child having sessions or BOTH have Mental Health Plans)*

a) Child Client
b) Adult Client

Child's Name*

First Last

Child's Date of Birth (eg 11/10/2002)*

1st Child's Name*

First Last

1st Child's Date of Birth (eg 11/10/2002)*

2nd Child's Name*

First Last

2nd Child's Date of Birth (eg 11/10/2002)*

Adult client NAME*

First Last

Adult's Date of Birth (eg 11/10/1978)*

Name of Emergency/Primary Contact person for Child (eg Parent 1)*

Mobile Number of Emergency/Primary Contact (NOTE: sms reminders will be sent here)*

Name of Secondary Contact person for Child (eg Parent 2)*

Mobile number of Secondary Contact*

Email Address (to send invoices and correspondence)*

Mobile Number (for sms appointment reminders)*

Full Name of Clients Emergency Contact*

Mobile Number of Emergency Contact*

How did you hear about Sunlight Psychology?*

Google/Searching Online
A friend
GP
Paediatrician
Occupational Therapist
Speech Therapist
School staff (Guidance Officer/teacher)

How will you claim a REBATE*

Medicare - a Mental Health Plan will be used
Private Health Insurance
No Rebate - but a paid invoice to be emailed
NDIS funding
National Redress Funding

NDIS funded clients - Services provided by your psychologist will be supplied as one or more of the reasonable and necessary supports specified in your NDIS Plan (under subsection 33(2) of the NDIS Act).

Please email a copy of your NDIS Plan to info@sunlightpsychology.com.au

How is your NDIS funding managed (who pays the invoices):

Self Managed (we take payment off your card and send you an invoice after each session to claim from the NDIS)
Plan Managed (we send invoices to your plan manager)

NDIS Participant Number (on your NDIS plan and paperwork):*

Name of your plan manager organisation that manages your NDIS invoices*

Accounts email address of the plan manager organisation that pays your invoices*

Private Health Insurer Name (Eg BUPA, Medibank or HCF)*

Private Health Membership Number*

ADULT Medicare Card number*

NUMBER in front of ADULT's name on the MEDICARE CARD (eg 1, 3)*

CHILD Medicare Card Number*

NUMBER in front of CHILD's name on the MEDICARE CARD (eg 1, 3)*

1st CHILD's Medicare Card Number*

NUMBER in front of 1st CHILD's name on the MEDICARE CARD (eg, 1, 3)*

Does the 2nd CHILD have the same Medicare card number as the 1st CHILD (i.e. the Medicare number you entered above)*

Yes - It is the same as I entered Above
No - They have a different Medicare number

2nd CHILD's Medicare Card Number*

NUMBER in front of 2nd CHILD's name on the MEDICARE CARD (eg, 1, 3)*

Address REGISTERED WITH Medicare*

Address Suburb Postcode

Home address of the client*

Address Suburb Postcode

Is your BANK ACCOUNT registered with Medicare*

YES - Medicare Rebates will be paid into this account
NO/UNSURE - You will need to contact Medicare to register your bank account either Before or After your first session

NAME OF PARENT Claiming the Medicare Rebate (ie who the Rebate is paid to)*

DATE OF BIRTH of PARENT Claiming the Medicare Rebate*

Does the PARENT CLAIMING REBATE have the same Medicare card number as the child/children (i.e. the Medicare number you entered above)*

Yes - It is the same as I entered Above
No - I have a different Medicare number

Different Medicare Card Number of PARENT CLAIMING REBATE*

NUMBER in front of PARENTS's NAME on the MEDICARE CARD (eg 1, 3)

IMPORTANT - if you want to claim Medicare rebates YOU need to email us a copy of a Mental Health Treatment Plan (MHP) or referral from your GP or Psychiatrist BEFORE the first session. The referral NEEDS TO STATE THE NUMBER OF SESSIONS THE DOCTOR APPROVES and have Christina's name on the referral for us to be able to give you medicare rebates. If it does not meet these requirements you will not get a Medicare rebate.

Your referring GP's (or Psychiatrist's) first and last names

What is the date of your 1st or next booked session (Eg 02/09 or 04 Oct)

Disclaimer and Consent

All our services and your use of this website are subject to our Privacy Policy and the Terms and Conditions listed below:

1. Either Ana Catton, Heather Garner (intern psychologist) or Christina Birch of Sunlight Psychology is your "treating psychologist" responsible for your care, you are "the client" (yourself or the child or adolescent you are organising services for), and Changes Psychology is the admin and billing service "provider" that is only responsible for processing clients' bookings, billing and client administration only on behalf of your treating psychologist. By signing this agreement you are agreeing to the provision of services under this arrangement

2. Privacy - Sunlight Psychology and Changes Psychology take your privacy seriously. We work like a virtual clinic office, collecting and managing personal and health information provided by you and your psychologist, which naturally includes sensitive health information. We collect, use and (where appropriate) share this information, which includes health information, in order to facilitate appointments with psychologists; manage payments, medicare and insurance claims; and manage records regarding your appointments. We manage your information in accordance with industry standards and applicable Privacy laws. Our handling of personal information involves storage and processing of some data by contracted staff who are based offshore in the Philippines, and also by staff that are based in Australia. For more about privacy, and who to contact if you have questions or complaints regarding privacy please read the admin provider's privacy policy here Privacy Policy.

3. Your treating psychologist will not provide information, reports or documentation for medico-legal or family court related purposes unless required to by law, under a subpoena or by a court order.

4. Parenting plans - if there is a parenting plan or consent order in place we require the parent or person engaging the treatment to meet the all requirements of the plan. It is not our responsibility to share information with other parents or stakeholders.

5. Information sharing - If you would like the psychologist to share and collect information about your child with your ex-partner/teacher/OT etc, we need written consent from you to approve this sharing of information with each individual. However if you intend to claim rebates from Medicare or another organisation is paying for the services, then your psychologist must provide summary reports to the referring GP, Paediatrician, Psychiatrist or external agencies regarding your treatment progress in order to be able to give you Medicare rebates and meet the legal obligations of this funding. By agreeing to these terms and conditions you agree to this information sharing policy.

6. Access to information – It is our obligation to protect the privacy of all of our clients. Providing you have legal authority to do so, you can discuss with your psychologist how to access information about your child that is kept on file. When a young person is of sufficient maturity and developmental capacity to understand the nature of their records and the implications of another person accessing their records, they must provide consent for disclosure of their personal information to one or both parents, and can withdraw consent at any time. Your psychologist will discuss confidentiality, and limits to, during you first appointment. By agreeing to these terms and conditions, you agree to this access to information policy.

7. Confirming your first appointment booking - To confirm the first session booking, all new clients consent to completing the Claiming, Consent and $1 session fee payment form via the online form and payment portal link that will be emailed to you within 48 hours of receiving the information email. You will have $1 session fee credit will be deducted immediately and your card details stored and securely encrypted within the NAB (National Australia Bank) Transact system for all future session fee payments

8. Attendance Policy and Fees- The session fee for all of your treating psychologist's services are $214 for NDIS funded sessions, and $215 for private and Medicare sessions. This amount will be deducted in full after every session from the stored credit/debit card you provide to us. Payment needs to be received before Medicare rebates or Private Health Invoices are processed. All payments will be taken via our online payment system NAB Transact after your session being completed. All payments will show up on your credit or debit card statement/online banking with the payment reference 'Changes Psychology Northgate' (NOT Sunlight Psychology).

9. Attendance at Sessions and Cancellation fee - Consistent attendance at appointments is part of helping you achieve your goals. We ask that you only make appointments that you intend to keep. When you book, the session time is set aside whether or not you choose to attend and the fee attached to that session will also be yours. If you do not attend, it is not possible to apply the Medicare rebate and the entire session fee will be charged.

If the appointment time is no longer suitable, it is important to let us know as soon as possible. To avoid paying the session fee you will need to let admin know 24 business hours prior to your appointment.

Alternatives to attending in person: i) You can change your appointment to an online or telehealth session, or ii) You can request that your psychologist use this time to write a report to a third party, or complete some research on your behalf.

If you suspect you/your child will be too unwell to attend your session the following day, then please err on the side of caution and reschedule your appointment, with more 24 hours notice.

If you cancel your first session the treating psychologist will retain the $1 booking deposit that can be used against future session bookings.

NDIS late cancellations are in line with NDIA guidelines.

To agree to the Terms & Conditions above, and Privacy Policy, SIGN IN THIS BOX with your finger (on mobile device) or use your mouse*

Sunlight Psychology Claiming and Consent form – to be completed by all new clients to receive their Medicare rebates or Private Health Invoices

Disclaimer and Consent