Select who will be the client (select BOTH a & b if parent & child having sessions or BOTH have Mental Health Plans)*

a) Adolescent Client (Anita only sees young people 13 and above)
b) Adult Client

Adolescent or Adult child's Name*

First Last

Adolescent or Adult 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 session reminders)*

How did you hear about LifePsyche?*

How will you claim a REBATE*

Medicare - a Mental Health Plan will be used
Private Health Insurance
Workcover Insurance (IMPORTANT - Email us your GP referral to the 1st session)
Employment Assistance Program (EAP) is paying for sessions
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*

Name of the Insurance Company (eg Workcover QLD or other insurer)*

Insurance Claim Number*

Case Manager Name*

Case manager email address*

What is the name of your EAP provider organisation and their email if you know it (as we will need to request approval documentation from them)*

ADULT Medicare Card number*

NUMBER in front of ADULT's name on the MEDICARE CARD (eg 1, 3)*

Adolescent or Adult child's Medicare Card Number*

NUMBER in front of the Adolescent or Adult 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)*

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 - when you get the MHP you need to take a picture of your MHP or referral on your phone/scan it and email it to us (taking it to the session will result in rebates taking longer to process)

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)

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

Please indicate if any of the following apply to you or the client:

To inform your treatment, please advise of any Medications, or Vitamin/Mineral supplements (including dosages) that you take:

Please describe your medical history (e.g. head injury, CVA, haemorrage etc) or family medical and mental health history. Provide approximate dates if possible

Are you or the client, meeting with Anita to discuss physical health or eating related concerns*

No - I am only seeing Anita for Mental Health related issues
Yes - I am seeing Anita in relation to physical health or eating related issues

Please indicate any problematic eating habits you would like to address

Picking/grazing
Rewarding self with food
Over-eating
Junk food
Emotional eating
Food weaknesses
Under-eating
Bingeing

Please describe your Daily Food Intake - provide a sample meal of the meals you would have for breakfast, lunch, dinner and snacks on a "good day" and/or a "bad day"

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. The LifePsyche staff member you see is your "treating 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 on behalf of your treating psychologist. By signing this agreement, you are agreeing to the provision of services under this arrangement.

2.Privacy - LifePsyche 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 in order to facilitate appointments with your psychologist and to manage payments including Medicare and health insurance rebates. 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.

4. Parenting plans - if there is a parenting plan in place, we require the parent or person engaging the treatment to meet all the 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. NEW CLIENTS - 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. 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. EXISTING CLIENTS - In order to transition existing clients to the new NAB payment system, we require all existing clients to complete our $1 payment form online. At the end of this form you will be required to enter your card details and provided signed consent in order to confirm your first booking. Eftpos facilities will not be available from 2020 onwards. Your card details will be processed for the $1 session fee credit stored and encrypted securely within the NAB (National Australia Bank) Transact system for all future session fee payments, so no-one will view your full card details.

8. Cancellation Policy - LifePsyche observes the cancellation policy proposed by the Australian Psychological Society (APS): If you need to cancel or reschedule your appointment, you must give us more than 48 hours' notice. If you provide between 24 and 48 hours' notice, and we cannot fill the time allocated for your appointment, you will be charged 50% of the consultation fee. If you give less than 24 hours' notice, and we cannot fill the time allocated for your appointment, you will be charged 100% of the consultation fee. If you cancel your first session the psychologist will retain the $50 booking deposit. This can be used against future session bookings.

9. The session fees for all LifePsyche's Services are listed here NOTE: 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. All payments will show up on your credit or debit card statement/online banking with the payment reference 'Changes Psychology Northgate' (NOT LifePsyche)

10. Medicare rebates - If the client is referred on a Medicare-rebated Mental Health Care Plan by their GP, the rebate will be $126.50 if they are consulting a clinical psychologist, and $86.15 if they are consulting a registered psychologist. Once the client reaches their Medicare Safety Net, their rebate will increase to 85% of the full fee. Clients are only eligible for Medicare rebates if they have provided a GP referral letter requesting services and a mental health treatment plan. We collect, use and (where appropriate) store this information in order to facilitate appointments with your psychologist and to manage payments including Medicare and health insurance rebates. Medicare rebates are processed after the full session fee has been successfully processed in our NAB online payment system. Medicare pays rebates directly in to the bank account you have registered with Medicare (NOTE: the bank account you have registered with Medicare may be a different account to the card you provided in our NAB system to pay session 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*

NOTE: $50 session credit for LifePsyche will be deducted now to confirm your booking. Your card details will be stored with NAB and used for future billing (AMEX 4.8 percent surcharge). Transaction Reference 'CHANGES PSYCHOLOGY NORTHGATE'

Price: $ 50.00

Press submit and proceed to the NAB Payment Page to enter your credit or debit card details to pay the $50 session fee credit to confirm your first session (your card details will be stored with NAB and used for future session fee payments)

$ 0.00

Please complete the LifePsyche $250 payment form to pay for your session fee. We will process your Medicare rebate or invoice when payment is received

Disclaimer and Consent