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)*

Entry to the practice is up a flight of stairs without a lift or wheelchair access. Is this ok with you or the client?*

Yes - It is fine to walk up stairs
No - I have mobility issues and cannot walk up stairs (please email us if this applies to you)

How did you hear about Lesley or Smyth Psychology?*

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

Is this client aged under 18 subject to current family court orders, current legal proceedings or are there any active court matters in relation to this client*

NO - there are NO family court orders, NO current legal proceedings and NO other active court matters in relation to this client
YES - there are family court orders, current legal proceedings or other active court matters in relation to this client and I agree to phone Reception on 55143005 before I continue completing this form

How will you claim a REBATE*

Medicare - a Mental Health Plan will be used
Private Health Insurance
Access Plus Funding (via the Primary Health Network) - please note you need to be approved for this funding before you can book a session
No Rebate - but a paid invoice to be emailed
Workcover (SIRA) Insurance (IMPORTANT -Email us your GP referral before your 1st session)
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)
NDIA managed (we cannot work under this type of funding)

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*

Private Health Membership Number*

Name of the Insurance Company (for Workcover/SIRA)*

Insurance Claim Number*

Case Manager Name*

Case manager email or phone 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 Lesley'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 with Lesley (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. Lesley Smyth of Smyth Psychology is your "practitioner" 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 practitioner. By signing this agreement you are agreeing to the provision of services under this arrangement

2. Privacy - Smyth Psychology takes your privacy seriously. We work like a virtual clinic office, collecting and managing personal and medical information digitally from you and your practitioner, 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 practitioners; 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 practitioner 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. Lesley does not provide reports, treatment summaries etc (other than those she is legally obligated to do). Should there be a need for such a report, referral options can be provided.

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 practitioner 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 practitioner 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 session fee payment form via the online form and payment portal link that will be emailed to you within 48 hours of receiving the information email. You will have $50 session fee credit will be deducted immediately and your card details stored and securely encrypted within the NAB (National Australia Bank) Transact system for all future session fee payments

7. Cancellation Policy - Cancellations made with less than 48 hours notice will attract a $50 cancellation fee in the first instance and then the full session fee ($220) will be charged for all subsequent cancellations and be taken off your stored card or you will be required to provide card details to pay for this before another session can be booked. Please be aware that cancellation fees cannot be claimed back from Medicare or private health funds.p/>

8. The session fee for all of your treating practitioner's services is $220 (in-clinic sessions) per 50 minute session. Longer sessions are charged at a pro‐rata rate. Fees for sessions held outside of the clinic, reports, telephone consultations and home/external visits are available on request. The owed session fee 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 of $129.55 or Private Health Invoices are processed. All session fee and cancellation fee payments will be taken via our online payment system NAB Transact after 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 Smyth psychology)

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

Lesley Smyth Psychology Claiming and Consent form

– we need you to complete this form so we have your information to allow us process your Medicare claim or billing.

Disclaimer and Consent