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 Legal Name (on Medicare card)*

First Name Last Name

Child's Preferred First Name (if different to legal name)

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

What is the child client's gender identity?*

Female
Male
Transgender Male/Trans Man/FTM
Transgender Female/Trans Woman/MTF
Gender Queer

What is the child client's preferred pronouns*

She/her
He/him
They/them

Your Legal Name as it appears on your Medicare Card to allow rebates (or the Adult client's if you are completing this form for them)*

First Name Last Name

Your preferred First Name (if different to your legal name)

Date of Birth (eg 11/10/1978)*

Your gender identity?*

Female
Male
Transgender Male/Trans Man/FTM
Transgender Female/Trans Woman/MTF
Gender Queer

Your preferred pronouns?*

she/her
he/him
they/them

Your Email Address*

Mobile Number (for sms appointment reminders)*

How did you hear about Deb Psychology?*

How will you claim a REBATE*

Medicare - a Mental Health Plan will be used – you need to email us a copy of your GP referral before the first session
Private Health Insurance
NDIS funding
Worksafe have approved sessions - you need to email us a copy of your GP referral before the first session*
TAC have approved sessions - you need to email us a copy of your approval for sessions and GP referral before the first session*
Victims of Crime (VOCAT) have approved sessions - you need to email us a copy of the approval letter AND the relevant court documents so we know who to invoice for sessions
DVA (Gold and White card holders) - please provide a copy of your GP referral*
Open Arms
No Rebate - but a paid invoice to be emailed

Clients Home Address*

Address Suburb Postcode

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

Self managed (you pay the session fee and we send you an invoice to claim from the NDIS)
Plan Managed (we send invoices to your plan manager)
NDIA/NDIS managed (NOTE: we are not registered with the NDIS to support clients under this funding type)

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*

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

Private Health Membership Number*

Name of your Worksafe Insurer*

Email of your Worksafe Insurance case manager*

Your claim/participant/approval number*

Please confirm the type of Worksafe approval you have*

I have 6 sessions of psychology approved (without liability)
I have approval for more than 6 sessions of psychology (with liability)

Name of your TAC case manager*

Email of your TAC case manager*

Phone number of your TAC case manager*

TAC claim or reference number*

Victims of Crime (VOCAT) claim or reference number*

Your DVA Gold or White card number*

Your 10 digit Medicare Card number (or the Adult Client's)*

NUMBER in front of your 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 have Deb's name on it for us to be able to give you medicare rebates. If the referral does not have Deb's name on it you will not get a Medicare rebate.

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

Fax number of the GP practice with 03 at beginning

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

Who is completing this form?

I am the client and completing the form for myself
I am NOT the client, I am completing this form on behalf of the clients

What are the difficulties for which you are seeking help?

What are your treatment goals?

Please select any Signs/Symptoms of mental health issues below that are relevant to the client having sessions

Please list any current medical diagnoses you have.

No
Yes

List all current prescription medications and how often you take them

Has any family member been treated with a psychiatric medication?

No
Yes

Do you regularly consume any of these substances?

Caffeine
Alcohol
Tobacco
Other drugs

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. Deb Anthony 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 - Deb Psychology and Changes Psychology takes your privacy seriously. We work like a virtual clinic office, collecting and managing personal and medical information digitally from you and your psychologist, 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 psychologists; 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 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 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. According to Medicare and the Department of Human Services, a valid referral MUST include

- The date of referral

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

$50 deposit ($50 session fee credit) towards your next session at Deb Psychology will be deducted now. Your card details will be saved for future billing (AMEX 4.8 percent surcharge). Transaction Reference will be 'CHANGES PSYCHOLOGY NORTHGATE'

Price:

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

$ 0.00

Deb 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