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 Changes Psychology?*

Your friend's name - so we can send them a thank you!

Is there a PARENTING PLAN or FAMILY COURT ORDER in place that relates to this child/children?*

Yes
No

Does the other parent/guardian need to be informed about, or want feedback on, sessions with this child? Or will they try to contact us?*

Yes
No

How will you claim a REBATE*

Medicare - a Mental Health Plan will be used
Private Health Insurance
NDIS plan managed funding - an organisation pays the invoices for you
NDIS self managed - you pay the invoices
No Rebate

NDIS participant number*

Name of the NDIS Plan Manager organisation*

Accounts email address of the NDIS plan manager organisation*

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

Private Health Membership Number*

The ADDRESS and SUBURB FOR SESSIONS (if sessions will be at our Northgate Clinic rooms please write that)*

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

If a DIFFERENT ADDRESS (to your Medicare address) WILL BE USED FOR SESSIONS please enter it here with the SUBURB (if sessions will be at our Northgate practice please write that)

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 Changes Psychology on the referral for us to be able to give you medicare rebates. If it does not meet these requirements you will not get a Medicare rebate.

GP Practice name & GP's Name (if you know them)

Has the ADULT CLIENT already used sessions under a Mental Health Treatment Plan (MHP) since the 1st of January this year?

NO
YES

How many sessions has the ADULT had under this MHP since the 1st of January this year? Enter UNSURE if you need us to check, as a maximum of 10 is permitted every year*

Has the CHILD CLIENT already used sessions under a Mental Health Treatment Plan (MHP) since the 1st of January this year?

NO
YES

How many sessions has the CHILD had under a MHP since the 1st of January this year? Enter UNSURE if you need us to check, as a maximum of 10 is permitted every year*

Has the 1st or 2nd CHILD already used sessions under a Mental Health Treatment Plan (MHP) since the 1st of January this year?

NO
YES

How many sessions has the 1st or 2nd CHILD had under a MHP since the 1st of January this year? Enter UNSURE if you need us to check, as a maximum of 10 is permitted every year*

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

Disclaimer and Consent

All our services and your use of this website are subject to our Privacy Policy and Terms and Conditions.

1. Privacy - Changes Psychology takes 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.

2. Provider will not provide information, reports or documentation for medico-legal, custody related, parenting plan or family court related purposes unless we required to by law, under a subpoena or by a court order.

3. 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.

4. 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.

5. 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, so no-one will view your full card details.

6. Cancellation Policy - If you cancel with less than 48 hours notice, you will be charged the full session fee amount for the cancelled session. You will note be able to claim a Medicare rebate for cancellation fees.

7. Payment for appointments will be taken via our online payment system NAB Transact where you card is collected, stored and used to pay for each session. By providing your card and signing this consent form you agree to this use of your card for all fees owed.

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

Press submit and Proceed to the NAB Payment Page to finalise payment. NOTE: If using a debit card, a $10 fee will apply to future transactions if there is an insufficient balance when we try to debit session fees

$ 0.00

$50 will be deducted from your card now, this is $50 credit towards your next session fee and will confirm your first session. These card details will be stored with NAB for future billing (AMEX 4.8 percent surcharge)*

Price:

Claiming and $50 booking deposit form

Disclaimer and Consent