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

Parent Name*

First Last

Adult's Date of Birth (eg 11/10/1978)*

Your Email Address*

Mobile Number (for sms appointment reminders)*

Which practice location will your sessions be held at*

Marrickville
Bankstown

Which Psychologist are you booked in to see

Rony Kayrouz
Steve Hansen
Soraya Mir

How did you hear about Psychodos?*

How will you claim a REBATE*

Medicare - a Mental Health Plan will be used
Private Health Insurance
No Rebate - but a paid invoice to be emailed

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

Private Health Membership 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

Address*

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 Psychodos or the psychologist'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 (Eg 02/09 or 04 Oct)

Consent to our Terms and Conditions

All our services and your use of this website are subject to our Privacy Policy and our Terms and Conditions listed below:

1. Either Rony Kayrouz, Steve Hansen or Soraya Mir are your "treating practitioner" responsible for your treatment and 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 psychologist. By signing this agreement you are agreeing to the provision of services under this arrangement

2. Privacy - Psychodos 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 information, in order to facilitate appointments with psychologists; 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 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. Parenting plans - if there is a parenting plan in place we require the parent or person engaging the treatment to meet 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 yourself or other stakeholders e.g. your ex-partner/teacher/caseworker 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. Sessions fees and charges - all session fees are collected via stored credit card in Halaxy or bank transfer or cash at the end of each completed session. Our fees can be found by clicking on this link http://www.psychodos.com.au/bookings-inquiries/

7. Cancellation Policy - If you cancel your first session with less than 24 hours notice, Psychodos will charge you 50% of your usual session fee amount. This cancellation fee must be paid prior to new appointment bookings. If you wish to cancel or re-schedule an appointment without cost, we require more than 24 hours notice.

8. The purpose of the psychological therapy session is for you, the client, for therapy use only, and use of video or audio recording is not permitted to be used by the treating practitioner or by the client, for any other purposes, including providing the recording to anyone else in person or on social media". Where it is required, a video, telephone or online (telehealth) consultation may be offered.

9. The telemedicine solution designed for health practices used in this practice is ZOOM. It is a cloud-based system for video and audio conferencing and no information about the session is saved on the provider’s site and no account is required to use the service. The provider states at least 128-bit AES encryption.

10. I understand the following: A telehealth consultation will not be exactly the same, and may not be as complete as a face-to-face service and this may affect the psychologist’s ability to respond within my expectations. The capacity for crisis intervention may be diminished. There could be some technical problems that affect the telehealth consultation. The health care service uses systems that comply to recommended Australian standards to protect the privacy and security of the video and telephone consultations. However, the service cannot guarantee total protection against hacking or tapping into the video visit by outsiders including tracking your location. This risk is small, but it does exist.

11. It is still unclear whether a service delivered over the internet is considered to be from the place where it is provided or the location in which it is received for registration, insurance and legal purposes. If the telehealth consultation does not achieve everything that is needed, then I can choose what to do next. I can change my mind and stop using telehealth consultations at any time, including in the middle of a video or telephone consultation. I will still have the right to ask for and receive health care.

12. Medicare will be temporarily be allowing rebates and bulk billing for telehealth sessions in 2020 during the Coronavirus crisis. I understand that in many cases a rebate will not be payable for my appointment. This is dependent on the service (Medicare/DVA/private health insurance) and the circumstances (video/ telephone/online mode or emergency circumstances). This will be clear before my appointment.

I acknowledge that I have read and understood the above conditions and agree to these conditions for any telehealth service provided by my treating practitioner.

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

Consent & Client Claiming Form for all Psychodos New Clients- complete this form before your first session so we can process your Medicare Rebate or Private Health claims

Consent to our Terms and Conditions