Child psychologist

The Mind Body Practice – $1 payment form

This form is to be completed by clients so we can collect their card details in our NAB online payment system and use these saved card details to deduct all  session fees payments.

If form is not working or you have any questions please call (02) 8091 7867 or email

  • 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. Any of the psychologists you see through the Mind Body Practice are your "treating psychologist" responsible for your care, you are "the client" (yourself or the person you are organising services for), and Changes Psychology is the admin and billing service "provider" that is responsible for processing clients' bookings, billing and client administration only on behalf of your treating psychologist. By signing this agreement you are agreeing to the provision of services under this arrangement

    2. Privacy - The Mind Body Practice 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, which includes health and medical information, in order to facilitate appointments with psychologists; manage session payments, medicare and insurance claims; and manage records regarding your appointments. We manage your information in accordance with 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 psychologist 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. All personal information gathered by the psychologist during the provision of the psychological service will remain confidential except when:

    i) It is subpoenaed by a court, or disclosure is otherwise required or authorised by law; or

    ii) Failure to disclose the information would in the reasonable belief of The Mind Body Practice place you or another person at serious risk to life, health or safety; or

    iii) Your prior approval has been obtained to:

    a) provide a written report to another professional or agency. e.g., a GP or a lawyer; or

    b)discuss the material with another person, e.g. a parent, employer, health provider or third-party funder; or

    c) disclose the information in another way; or

    d) disclose to another professional or agency (e.g. your GP) and disclosure of your personal information to that third party is for a purpose which is directly related to the primary purpose for which your personal information was collected.

    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. 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.

    7. Please note that The Mind Body Practice does not provide emergency or crisis services. If you require immediate assistance, please call 000 or phone Lifeline on 13 11 14 urgent counselling.

    8. Confirming your first appointment booking - 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 and 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.

    9. Cancellation Policy - If you cancel your first session the psychologist will retain the $50 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 less than 24 hours before the appointment time will be charged the full session fee.

    10. The session fee for you services provided by Clinical Psychologist Dr Shilpa Madiwale is $195 per 50 minute session, and the fee for other Psychologists is $170 per 50 minute session. Also sessions 4pm or later on any day also attract a $10 surcharge. Session fees may also be increased periodically to cover increased practice costs.

    11. Session fee payments 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 within 24 hours of your session being completed. By providing your card details you consent to them being stored and used to pay for session fees. All payments will show up on your credit or debit card statement/online banking with the payment reference 'Changes Psychology Northgate' (NOT The Mind Body Practice)

  • Price: $ 1.00
  • $ 0.00