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)*

How did you hear about Don or Mackenzie Social Work Services?*

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 - NOTE: Only Teachers Health, UniHealth, Nurses and Midwifes Health pay rebates for social workers (other Health Insurers do not)
No Rebate - but a paid invoice to be emailed
Workcover (SIRA) Insurance (IMPORTANT -Email us your GP referral before your 1st session)
NDIS funding (NOTE: Concession fees DO NOT apply to NDIS funded clients)

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 (only Teachers Health, UniHealth, Nurses and Midwifes Health)*

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)

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 Don (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. Don Mackenzie of Mackenzie Social Work Services 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 - Mackenzie Social Work Services 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.

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 - If you cancel your first session the treating practitioner will retain the $1 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 24 hours notice. Session bookings cancelled with less than 24 hours of the appointment time the full session fee will be deducted off your stored card or you will be required to provide card details to pay for this before another session can be booked.

8. The session fee for all of your treating practitioner's services is $175 (in-clinic sessions) per 50 minute session, and a concession rate of $125 per 50 minute session for Centrelink Concession Card holders. 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 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 Mackenzie Social Work Services)

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 Mackenzie Social Work Services will be deducted now to confirm your booking. Your card details being stored with NAB 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 $1 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

Mackenzie Social Work Services Claiming, Consent and $50 deposit form

$50 credit towards your first session – to be completed by all new clients to confirm their first session booking.

Disclaimer and Consent