Full name of client*

First Last

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

Email Address*

Mobile Number (for sms appointment reminders)*

Name of Emergency Contact/Next of Kin*

First Last

Emergency Contact Phone Number*

How did you hear about your Psychologist Dina Dehauteur?*

Which practice room location have you booked to see Dina for the next session*

Randwick
Maroubra Junction
Coogee Medical Centre

How will a REBATE be claimed for psychology sessions:*

Medicare - a Mental Health Plan will be used
Private Health Insurance
No Rebate will be claimed

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

Private Health Membership Number*

Client Medicare Card number (10 digit number)*

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

Address REGISTERED WITH Medicare*

Address Suburb Postcode

Is your BANK ACCOUNT registered with Medicare (rebates go back to this card, NOT back onto the card you paid with)*

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

If you have a Mental Health Treatment Plan (MHP) or referral from your GP or Psychiatrist already, we need you to enter some information from it below to be able to process your rebate faster. Or leave the following boxes blank if you to not have a copy of your MHP or referral with you now. IMPORTANT - when you get the MHP you need to take a picture of your MHP or referral on your phone/scan it and email it to us (taking it to the session will result in rebates taking longer to process)

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 (Eg 02/09 or 04 Oct)

Disclaimer and Consent

All our services are subject to our Privacy Policy and Terms and Conditions. Here are some key points about our services:

1. Dina Dehauteur, is your "Provider" and treating psychologist responsible for your care, you are "the client", and Changes Psychology is the "admin and billing service provider" that only manages Dina's clients' bookings, billing and client administration.

2. Privacy - Dina Dehauteur and Changes Psychology take your privacy seriously. We work like a virtual clinic office, collecting and managing personal and medical information provided by you and your psychologist, which naturally includes sensitive health information. We collect, use and (where appropriate) share 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 industry standards and applicable laws. Our handling of personal information involves storage and processing of some data overseas. For more about privacy, and who to contact if you have questions or complaints regarding privacy, see our Privacy Policy.

3. Provider, or admin and billing service provider, will not provide information, reports or documentation for medico-legal or family court related purposes unless we required to by law, under a subpoena or by a court order.

4. Confirming your first appointment booking - Fee paying clients consent to paying a $50 booking deposit (that will be $50 credit towards your first session) via the secure payment portal link to NAB that will be emailed through to you within 48 hours of receiving the email- your card details will be processed for the $50 deposit only and held for future billing of future psychology appointments within the NAB (National Australia Bank) Transact system

5. Cancellation Policy - If you cancel your first session we will retain the $50 booking deposit. If you wish to cancel or re-schedule an appointment, we require at least 48 hours notice and appointments cancelled within 48 hours of the appointment time will attract a $50 cancellation fee. If you cancel with less than 12 hours notice, you will be charged the full amount for the cancelled session.

6. Payment for appointments will be taken via our online payment system NAB Transact and you card will be stored within this system. All future fees and charges owed will be deducted from this stored card.

To agree to these policies SIGN IN THIS BOX with your finger (on mobile device) or use your mouse*

PLEASE NOTE: Changes Psychology processes payments and rebates for Dina Dehauteur (your treating clinical psychologist)- 'CHANGES PSYCHOLOGY NORTHGATE' will show as your transaction reference (AMEX additional 4.8 percent surcharge)*

Price: $ 50.00

Press submit and Proceed to the NAB Payment Page to enter your card details (which will be stored for future session fee payments)

$ 0.00

Dina D Psychologist -$50 booking deposit and Rebate Claiming Form (Medicare or Private Health)

Disclaimer and Consent