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 Consent

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

1. Gladiss Warda 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. Aberfoyle Psychology is the location of the practice rooms used for sessions. By signing this agreement you are agreeing to the provision of services under this arrangement

2.Privacy - Gladiss Warda 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. Confirming your first appointment booking - To confirm the first session booking, all new clients consent to completing the Claiming, Consent and $50 booking deposit (that will be $50 credit towards your first session) via the online form and payment portal link that will be emailed to you within 48 hours of receiving the information email- your card details will be processed for the $50 deposit only and your card details stored securely encrypted within the NAB (National Australia Bank) Transact system for all future session fee payments, so no-one will view your full card details.

7. Cancellation Policy - A cancellation fee equal to the full session fee is payable if a cancellation is made less than 24 hours notice prior to scheduled appointments. If you cancel your first session the psychologist will retain the $50 booking deposit that can be used against future session bookings. If you wish to cancel or re-schedule an appointment without cost, we require at least 48 hours notice

8. The session fee for all of your treating psychologist's services is $280 per 50 minute session, and this amount will be deducted in full after every session from the stored credit/debit card you provide to us. Payment needs to be received before Medicare rebates or Private Health Invoices are processed. All session fee and cancellation fee payments will be taken via our online payment system NAB Transact within 24 hours of your session being completed. All payments will show up on your credit or debit card statement/online banking with the payment reference 'Changes Psychology Northgate' (NOT Gladiss Warda Psychology

9. Phone consultations of 10 minutes or more will attract a fee of the appropriate part of the usually one hour fee. A fee for report/letter writing is payable when such documents are requested. When attending treatment with a Mental Health Care Plan provided by a GP, psychiatrist or paediatrician, only sessions attended by the named client on the plan will be rebated by Medicare. Please note that neither Medicare nor Private Health Funds provide rebates for 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 Consent