Full name of client*

First Last

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

Is the client (either yourself or person having sessions) a child under 18 years old?*

No - the client is an adult 18 years or older
Yes - the client is a child under 18 years (so the medicare rebate needs to get paid to an adult)

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 Hendriks Psychology?*

the GP's Name

The referring Health Professional's Name

Which Psychologist have you booked in to see:*

Justin Hendriks
Luke Vu

How will a REBATE be claimed for psychology sessions:*

Medicare - a Mental Health Plan will be used
Private Health Insurance
Department of Veterans Affairs (DVA) are paying for these sessions
Garrison Health Services (by Medibank) are paying for sessions
Vietnam Veterans Counselling Service (VVCS) are paying for sessions
NDIS - National Disability Insurance Scheme (you must have an approval letter to use this)
Workcover/Work injury/CTP Insurance is paying - you will email us the approval letter
No Rebate will be claimed (and we can email you an invoice)

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

Full Name of the Adult that the Medicare rebate needs to be paid to (the Claimant)*

Date of Birth (DOB) of the Adult Claimant that the Medicare rebate needs to be paid to (the Claimant)*

Is the Adult Claimant's Medicare card number (10 digits on the Medicare card) the same as the child client above

Yes - the Adult claimant's Medicare card number is the same as the child client's
No - the Adult claimant has a different Medicare card number (please type it in the box below)

The Medicare card number (10 digits) of the Adult claimant*

What is the number in front of the Adult Claimant's name on the Medicare card (eg 1, 2 or 3 usually)*

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 - you need to take a picture of your MHP or referral on your phone/scan it and email it to us

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)

Department of Veterans Affairs (DVA) Card Number:

What type of DVA card do you have:

Gold Card
White Card
Orange Card

What is your DVA card number:

Garrison Health Services (by Medibank) Defence Approval Number (DAN)

Garrison Health Services (by Medibank) Entitled Person ID (EPID), also known as your PM Keys

Vietnam Veterans Counselling Service (VVCS) number:

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

Terms and Conditions and Consent

1. Hendriks Psychology provides a "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 (no client welfare or service outcomes). By signing this agreement you are agreeing to the provision of services

2. Privacy - 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. For more about privacy, and who to contact if you have questions regarding privacy, see our Privacy Policy

3. Medicare clients - For clients who have been referred by a GP, Psychiatrist or Paediatrician, our psychologists are required by Medicare to write a letter back to the referring doctor detailing your assessment, treatment and progress after the completion of a block of sessions approved by your Mental Health Treatment Plan or referral.

4. Session fees for 2018 - for Clinical Psychologist Justin Hendriks are $200 for sessions before 5pm and $210 for sessions after 5pm. For Luke Vu his session fees are $173 with Medicare Rebate and $180 for Private Health Insurance clients. If you have previous written arrangement with your psychologist for a lower session fee rate, this lower rate will be charged. Also note that there will be annual session fee increases annually to cover increased practice costs

5. Confirming your first appointment booking - Fee paying clients (this excludes DVA and VVCS clients) consent to paying a $50 booking deposit (that will be $50 credit towards your first session) either over the phone to a receptionist upon booking or by providing card details to your psychologist at your session. Your card details will be debited, using our Health Kit practice management software, for the $50 deposit and your card details saved for future billing of all session fees and charges

6. Payment for all session fees and other charges will be deducted from your stored credit or debit card stored within our software Health Kit for which there is a $3 surcharge per session fee. It is the client's responsibility to provide their card details upon making a booking, to ensure card details are up to date and valid (or contacting us if they are not to provide new details) and to ensure there are sufficient funds on the debit card or otherwise a $10 insufficient funds fee will apply.

7. Cancellation Policy - If you cancel your first session we will retain the $50 booking deposit. If you wish to cancel or re-schedule a session, we require at least 48 hours notice, sessions cancelled between 24-48 hours are charged half the full fee and appointments cancelled within 24 hours of the appointment time will result in the full session fee being deducted from your card.

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

Hendriks Psychology Consent & Client Claiming Form (all Justin Hendriks & Luke Vu Clients need to complete this form so we can process Medicare Rebates & invoices)

Terms and Conditions and Consent