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 Port Psychology?*

How will you claim a REBATE*

Medicare - a Mental Health Plan will be used
Private Health Insurance
Employment Assistance Program (EAP provider) will be paying for sessions, and I already have approval from them. Please ensure the EAP provider has emailed us the written approval for sessions otherwise you will have to pay for sessions
No Rebate - but a paid invoice to be emailed
NDIS funding
Victims of Crime
Workcover insurance

Name of the EAP organisation your company uses (as we need to receive written approval from them approving sessions)*

How is your NDIS funding managed (who pays the invoices)*

Self managed (you pay for the session via a stored card, then we send you an invoice to claim from the NDIS later. It is not possible to invoice you to pay later)
Plan Managed (we send invoices to your plan manager)
NDIA/NDIS managed (Neither Ben or Krystal are registered and can see NDIA managed clients - you will not be able to use this funding with Port Psychology)

NDIS Participant Number (on your NDIS plan and paperwork):

Name of your plan manager or organisation that manages your NDIS invoices

Email address of the plan manager or organisation paying the invoices*

Private Health Insurer Name (Eg BUPA, Medibank or HCF)*

Private Health Membership Number*

The client's address

Street Address Suburb Post code

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)

Which clinician are you booked in to see?*

Ben French
Krystal Hawkins

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

Which school does your child attend and what grade are they in (NOTE: we will not contact the school without your consent, however we need to ensure there are no conflicts of interest)*

Please select any Signs/Symptoms of mental health issues below that are relevant to the client having sessions

Please describe the history, severity and impact of the issues you ticked above. Or any other helpful information for your treating practitioner

Goals for treatment - what are we working towards?

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. Either Ben French or Krystal Hawkins are the"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 only on behalf of your treating practitioner. By signing this agreement you are agreeing to the provision of services under this arrangement

2.Privacy - Port Psychology takes your privacy seriously. We work like a virtual clinic office, collecting and managing personal and medical information digitally from you and your treating 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 treating 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 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 treating 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 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.

7. Cancellation Policy - If you cancel your first session the treating practitioner 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 with less than 24 hours notice of the appointment time will attract a $50 cancellation fee.

8. The session fee for all of your treating practitioner's services is $150 per 50 minute session for session with Ben French and $140 per 50 minute session with Krystal Hawkins, and fees may increase in future years to cover practice costs. The session amount owing 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 payments will show up on your credit or debit card statement/online banking with the payment reference 'Changes Psychology Northgate' (NOT Port 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*

NOTE: $50 session fee credit for Port Psychology 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 will be '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 deposit ($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

Port Psychology Claiming, Consent and $50 deposit form ($50 credit towards your session) – to be completed by all new clients to confirm their first session booking.

Disclaimer and Consent