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)*

Name of your Emergency Contact/Next of kin*

Mobile number of your Emergency contact*

Names and ages of other children (besides the children listed above) that live in the same household. Please write NONE if there are no other children*

How did you hear about Gladiss Warda Psychology?*

Google/Searching Online
A friend
GP
Paediatrician
Occupational Therapist
Speech Therapist
School staff (Guidance Officer/teacher)

Are there any custody orders in place?*

No
Yes

If there are custody orders, please explain*

How will you claim a REBATE*

Medicare - a Mental Health Plan will be used
Private Health Insurance
No Rebate - but a paid invoice to be emailed
NDIS funding

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*

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)

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 Gladiss's name 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.

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

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

Disclaimer and Informed Consent

All our services and your use of this website are subject to the Privacy related Terms and Conditions listed below:

1. Parties who access your personal information

“You” – the client receiving therapy, or the parent/guardian/person arranging services.
Your treating “psychologist” – Gladiss Warda of Gladiss Warda Psychology.
Administrative/billing “provider” – Changes Psychology manages bookings, billing and claims.
Practice “software” – Halaxy, Dropbox, Gmail and other secure platforms.

Collectively, all parties (except you) are referred to as “we”. By signing, you acknowledge the roles of your psychologist, provider, and software.

2. Informed consent

Your psychologist will explain treatment purpose, process, benefits, risks and alternatives.
You may ask questions, request changes, seek second opinions or withdraw consent anytime.
Consent may be reviewed if treatment goals, risks, fees or parties involved change.
You may withdraw consent for information sharing, noting this may affect service provision or rebate eligibility.

3. How we use your personal information

We collect and manage personal and health information to operate as a virtual clinic office.
Information is used to:
- facilitate appointments
- manage payments, Medicare and insurance claims
- maintain accurate appointment records
Information is managed according to legal and industry standards.
Storage: Records are securely stored in Halaxy and Dropbox using encrypted, access-controlled systems.

4. Confidentiality and limits to confidentiality

Information is confidential except when:
- subpoenaed by a court
- there is immediate risk of harm to yourself or others
- you provide prior approval to:
  - give a report to another professional/agency
  - discuss information with another person
- a regulatory or funding body requests information
- disclosure is legally, ethically or professionally required

5. Information sharing

Written consent is required to exchange information with ex-partners, teachers, health professionals or others.
For Medicare or funded services, summary reports must be provided to the referring practitioner or agency.

By agreeing, you consent to this necessary information sharing.

6. Peer supervision

Your information may be shared in de-identified form for peer supervision to support best practice.
You may opt out by advising your psychologist.

7. Consent for note-taking software

Your psychologist uses Goodnotes or Novonote for AI assisted scibing and note-taking.
Summaries are drafts, not full transcripts.
You may opt out anytime.
Privacy information: Goodnotes Privacy Policy and Novonote Privacy Policy

8. Consent for telehealth sessions

Services may be provided via phone or videoconference.
Internet communication carries security risks—please use a private, secure location.

9. Session fees and payment

Fees are provided in your confirmation email.
Fees may increase over time.
New clients must complete the claiming/consent form and $50 booking deposit (credited to first session).
Card details are securely stored in NAB Transact via Changes Psychology.
Payments appear as “Changes Psychology” on statements.
Payments and Medicare rebates are processed after the session.
Phone consultations (10+ mins) incur proportional fees.
Report and letter writing attracts additional fees.

10. Cancellation policy

24 hours' notice required to cancel or reschedule without cost.
Less than 24 hours’ notice incurs a fee equal to the full session fee.
Clients funded by Workcover, EAP or similar must personally pay cancellation fees.

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

Gladiss Warda Psychology Claiming and Consent form

Disclaimer and Informed Consent