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

a) Adult Client
b) Young person (13-18 year olds only)

Adult client NAME*

First Last

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

Young person's Name*

First Last

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

Your Email Address*

Mobile Number (for sms appointment reminders)*

Next of Kin/Emergency Contact Name*

Next of Kin/Emergency Contact Phone number (mobile preferred)*

Where did you hear about Matt or Foresight Clinical and Forensic Psychology*

Google search
A friend
My referring GP
Another health professional

Psychologist you are booked with*

Tegan Murray
Matthew Ferriman

How will you claim a REBATE*

Medicare - a Mental Health Plan will be used
Private Health Insurance
EAP funding - Lifeworks EAP has approved psychology sessions for you with Matt only (NOTE: No other EAP funding including SMG health is able to be used to pay for sessions)
DVA (Gold and White card holders) - please provide a copy of your GP referral
No Rebate - but a paid invoice to be emailed
Insurance company is paying for sessions (NOTE: Matt cannot see you under Workcover funding)
NDIS funding

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)
NDIA managed (we cannot work under this type of funding)

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*

Private Health Membership Number*

Name of the Insurance Company paying for sessions*

Insurance Claim Number or reference (if you know it)

Case Manager Name*

Case manager email or phone number*

Address

Address Suburb Post code

ADULT Medicare Card number*

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

YOUNG PERSON'S Medicare Card Number*

NUMBER in front of YOUNG PERSON'S name on the MEDICARE CARD (eg 1, 3)*

Address REGISTERED WITH Medicare*

Address Suburb Postcode

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)

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

Your DVA Gold or White card number*

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 Matthew's or Tegans 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 to Terms and Conditions

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

1. Agreed parties - Matthew Ferriman of Foresight Clinical and Forensic Psychology is your "treating practitioner" 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 practitioner. By signing this agreement you are agreeing to the provision of services under this arrangement

2.Privacy - Foresight Clinical and Forensic Psychology takes your privacy seriously. We work like a virtual clinic office, collecting and managing personal and medical information digitally from you and your treating practitioner, which naturally includes sensitive health information. We collect, use and (where appropriate) store this information, which includes health information, in order to facilitate appointments with treating practitioners; manage payment, medicare and insurance claims; and manage records regarding your appointments. We manage your information in accordance with our ethical guidelines. For more about privacy, and who to contact if you have questions or complaints regarding privacy, see our Privacy Policy

3. Your treating practitioner 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 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 treating practitioner 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. Cancellation Policy - If you wish to cancel or re-schedule an appointment without cost, we require at least 24 hours notice. Session bookings cancelled with less than 24 hours notice of the appointment time, or no shows, will attract in a cancellation fee and retain deposit or authorise debiting of your credit card).

7. Confirming sessions and punctuality - it is your responsibility to confirm SMS appointment reminders and to ensure you are aware of and keep scheduled session times saved in your calendar. It is also your responsibility to attend session on time as you if you arrive late the consultation will still finish at the same scheduled time.

8. Unless agreed to with your treating psychologist, initial appointments are 80 minutes and charged at $330. All subsequent sessions are $220 per 50 minute session. All sessions are payable using the card you will provide for the $50 deposit ($50 session fee credit) at the end of this form. Session fees will increase periodically to cover increased practice costs. Foresight Clinical and Forensic Psychology DOES NOT Bulk Bill clients. All clients must pay for sessions via stored card before a Medicare rebate can be processed for them. Direct deposit is not a payment option.

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

NOTE: $50 session fee credit for Foresight Clinical and Forensic Psychology will be deducted now to confirm your booking and card details stored with NAB for future billing (AMEX 4.8% surcharge). Transaction will show 'CHANGES PSYCHOLOGY NORTHGATE'*

Price:

Press submit and Proceed to the NAB Payment Page to enter your credit or debit card details to pay the $50 deposit ($50 session fee credit) to confirm your first session (your card details will be stored with NAB and used for future session fee payments)

$ 0.00

Foresight Foresight Clinical and Forensic Psychology Claiming, Consent and $50 deposit form ($50 credit towards your session) – to be completed by all new clients to confirm their first session booking.

Disclaimer and Consent to Terms and Conditions