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
c) 2 Child Clients

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)*

Your Email Address*

Mobile Number (for sms appointment reminders)*

How did you hear about Amanda Elliott 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

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

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 Amanda's name on it 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 Informed Consent

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

1. Parties who access your personal information

“You” – the client receiving therapy, or the parent/guardian/person arranging services for a child, adolescent or another adult.
Your treating “psychologist” will be Amanda Elliott of Amanda Elliott Psychology, responsible for your assessment, treatment and clinical care.
Administrative/billing “provider” – Changes Psychology manages bookings, billing and Medicare/private health claims on behalf of your psychologist.
Practice “software” – including Halaxy, Gmail, Google Drive and other secure software applications used to deliver services.

Collectively, we refer to all parties involved in your care (except you) as “we”.

By signing this document, you acknowledge the roles of your psychologist, the provider and the software used to deliver your care.

2. Informed consent

Your psychologist will explain the purpose of treatment, how it works, the potential benefits and risks, and any alternatives.
You may ask questions, request changes, seek a second opinion or withdraw consent at any time by speaking with your psychologist or emailing us.
Consent may be reviewed if treatment objectives, risks, fees or involvement of other parties change.
You may withdraw consent for us to share your information at any time; however, doing so may limit the services we can provide or affect eligibility for rebates.

3. How we use your personal information

We operate like a virtual clinic office, collecting and managing personal and medical information provided by you and your psychologist, including sensitive health information.
We collect, use and (where appropriate) share this information to:
- facilitate appointments with psychologists
- manage payment, Medicare and insurance claims
- maintain accurate appointment records
We manage your information in accordance with industry standards and applicable laws.
Storage: Client records are stored securely online in Halaxy and Google Drive using encrypted, access-controlled systems.

4. Confidentiality and limits to confidentiality

All personal information remains confidential and securely stored except when:
- it is subpoenaed by a court
- your psychologist believes you pose an immediate risk to yourself or others
- you have given prior approval to:
  - provide a written report to another professional or agency (e.g., GP, lawyer)
  - discuss information with another person (e.g., parent, employer)
- a regulatory or funding body requests information
- disclosure is required to comply with legal, ethical, professional or mandatory obligations

5. Information sharing

If you want your psychologist to share or receive information about you or your child with any third party (e.g., ex-partner, teacher, health professional), written consent is required for each person.
If you claim Medicare rebates or another organisation funds the service, summary reports must be provided to the referring GP, Paediatrician, Psychiatrist or funding body.
By agreeing to these terms, you consent to this required information sharing.

6. Peer supervision

Your information may be shared in a de-identified manner during peer supervision to support best practice and high-quality care.
Please advise your psychologist if you prefer your information not be used in this way.

7. Consent for telehealth sessions

Services may be provided via telephone or videoconference when appropriate.
Internet-based communication carries inherent security risks; please attend telehealth sessions in a private and secure location.

8. Session fees and payment

Session fees are advised in your confirmation email.
Fees may increase periodically with rising practice costs.
All new clients must complete the Claiming, Consent and $50 booking deposit form (the $50 is credited to your first session).
By providing your card details in the online consent form, you consent to secure encrypted storage within NAB Transact, managed by Changes Psychology.
Your stored card is used for all session fees and related charges.
All payments will appear on statements as Changes Psychology, not Amanda Elliott Psychology.
Payments and Medicare rebates are processed after the session, usually the next business day, and payment must be received before rebates are processed.

9. Cancellation policy

At least 24 hours’ notice is required to cancel or reschedule without cost.
Cancellations with less than 24 hours’ notice incur a fee equal to the full session fee, charged to your stored card.
Clients funded by WorkCover, EAP or other funding bodies must pay cancellation fees personally.

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

Amanda Elliott Psychology Claiming and Consent form – please complete so we can process your Medicare Rebates or Private Health Invoices

Disclaimer and Informed Consent