Name: Changes Psychology
Address: 105 Northgate Road, Northgate, QLD, 4013
Telephone: (07) 3062 4535
Price range: $

Parent/Callers FULL NAME

First Last

Suburb

Mobile Number (only landline if no reception)

Email (read back to them)

Child/Children's or Adult Client's FULL NAME

First Last

Client Age Range

Presenting issue specifics, therapy goals and context

Main presenting issues

DAYS they want or are available for sessions

TIMES they want or are available for sessions to start

Day Date Time 1st session confirmed in Gcal (leave blank if time still needs to be confirmed)

Claiming type*

Medicare - need to get MHPs to us (not paid)
Medicare - paid $50 at phone intake, need to get MHPs to us
Private Health or No Rebate (Not Paid at phone intake)
Private health or No Rebate - Paid $50 at phone intake
NDIS Client - already has funding approved and a NDIS funding letter
Helping Children with Autism (HCWA) or Better Start Funding - need to provide approval letter
Medicare - want Bulk Billing, need to get MHPs to us

Allocated Psychologist

Phone Intake Form 2 – to trigger emails to clients