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)*

Parent's (or guardian's) full name*

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 Courtney Tideman?*

Location for the sessions you have booked with Courtney:*

Location address for sessions (if sessions at not at the Port Psychology clinic)*

Street Address City

How will you claim a REBATE*

NDIS funding
Private Health Insurance
Medicare - you have an Enhanced Primary Care plan you would use addressed to Courtney
Another organisation is paying for your sessions
No Rebate - but a paid invoice to be emailed

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

Self managed (you will be emailed an invoice to pay after each session)
Plan Managed (we send invoices to your plan manager)
NDIA/agency managed (Courtney is NOT NDIS registered and cannot see NDIA managed clients)

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

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

Email address of the plan manager or organisation paying the invoices*

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

Private Health Membership Number*

Name of the company, organisation or charity paying for your sessions*

Email of the case manager we need to send invoices to (the person that has approved your sessions as we need to receive written approval to confirm they are paying for sessions)*

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)

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

Your referring GP's (or Psychiatrist's) Medicare provider number (it is on your Mental Health Plan or referral, as is 7 numbers + 1 Letter, eg 3485687T)

The date on the Mental Health Plan or Referral (12/01/2018)

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

Which school does your child attend and what grade are they in (NOTE: we will not contact the school without your consent, however we need to ensure there are no conflicts of interest)*

Please describe the history, severity and impact of the issues you ticked above. Or any other helpful information for your treating practitioner

Goals for treatment - what are we working towards?

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. Courtney Tideman is your "treating practitioner" responsible for your care, Port Psychology is not responsible for your care and is the practice that Courtney works with. You are "the client" (yourself or the child or adolescent you are organising services for). 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 - Courtney Tideman 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. Confirming your first appointment booking - You need to complete this claiming form before your first session to confirm your first session booking

7. Cancellation Policy - When Unable to Attend, cancel the appointment by 12pm the day prior, there is no fee. Cancellations without satisfactory notification, are billed at 50% of the scheduled appointment fee. Non-Attendances are billed at 90% of the scheduled appointment fee. Service will be discontinued when: client no longer requires intervention, client no longer wishes to continue intervention, three non-attendances or three unpaid accounts

8. The session fees and other costs for all of your treating practitioner's services are listed in the attached welcome pack document.

9. You agree to pay all invoices emailed to you via direct deposit to the bank account provided on the invoice for Courtney within 48 hours of the invoice being emailed to you.

To agree to the Terms & Conditions above, I acknowledge I have received, read, and understood the welcome letter. I am aware of the policies and procedures required for: service provision, appointment attendance, cancellations/non-attendance/discharge and fee structure. and Privacy Policy, SIGN IN THIS BOX with your finger (on mobile device) or use your mouse*

Courtney Tideman Claiming and Consent form – to be completed by all new clients to confirm their first session booking.

Disclaimer and Consent