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) Adolescent Client 16 or 17 years old (no children under 16)

Adult client NAME*

Salutation First Last Gender

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

Adolescent or Adult child's Name*

Salutation First Last Gender

Adolescent or Adult child's Date of Birth (eg 11/10/2002)*

Your Email Address*

Mobile Number (for sms session reminders)*

Your next of Kin/Emergency Contact Name*

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

How will you claim a REBATE*

Medicare - a Mental Health Plan will be used
Private Health Insurance
Workcover Insurance (IMPORTANT - Email us your GP referral )
DVA - Department of Veteran Affairs is paying (IMPORTANT - You need to email us your GP referral approving sessions)
Victims Services (and you have had funding approved)
NDIS funding
No Rebate - but a paid invoice to be emailed

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*

Name of the Insurance Company (eg EML or other insurer's name)*

Insurance Claim Number*

Case Manager Name*

Case manager email address*

Victims Services case number allocated to you (required for them to pay for sessions)*

DVA Gold or White card number*

ADULT Medicare Card number*

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

Adolescent or Adult child's Medicare Card Number*

NUMBER in front of the Adolescent or Adult child'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)*

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 Corinna'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

Address*

Street Address Suburb Postcode

What is the date of your 1st or next booked session with Corinna (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 - Corinna Lancaster 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 - Corinna Lancaster 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 will attract in a cancellation fee and retain deposit or authorised debiting of your credit card).

7. Confirming sessions and puntuality - 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 you are eligible for a concession rate, the cost of a consultation (usually around 55 minutes) is $160, which is payable at the beginning of the session by cash or credit/debit card. Note, session fees will increase periodically to cover increased practice costs.

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

Corinna Lancaster Psychologist Consent & Client Claiming form

Disclaimer and Consent to Terms and Conditions