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)*

Name of Emergency Contact/Next of kin*

First Last

Emergency Contact's mobile or landline*

The Psychology Spot practice rooms are up flight of stairs without a lift. Is this ok with you?*

Yes - I am fine to walk up the stairs
No - I have mobility issues and find stairs difficult. Please email us and we can organise a video session instead

Where did you hear about The Psychology Spot?*

How will you claim a REBATE*

Referral from your doctor (Medicare) - a Mental Health Plan will be used
Private Health Insurance
No Rebate - but a paid invoice to be emailed
Workers Compensation (SIRA)
Open Arms
NDIS funding

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

Self managed (you pay the session fee and we send you an invoice to claim from the NDIS)
Plan Managed (we send invoices to your plan manager)
Agency (NDIA) managed (we claim from the NDIS directly)

Client's Home Address*

Address Suburb Postcode

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

Plan manager or organisation that manages your NDIS invoices*

Email address of the plan manager to send our invoices to*

Name of the client's employer*

The Client's GP (Nominated Treating Doctor that wrote your Workcover Referral)*

Workcover Insurer (the name of the Insurance company)*

Date of injury (day/month/year)*

Claim Number (Note if you don't have it)*

Case Manager's Name*

Case manager's email*

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

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)

The referring GP's (or Psychiatrist's) first and last names

The 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 the 1st or next booked session (Eg 02/09 or 04 Oct)

Disclaimer and Consent

All our services and your use of this website are subject to our Privacy Policy, our admin service provider Paperless Admin's Privacy Policy and the Terms and Conditions listed below:

1. The Psychology Spot and it's psychologists are your "treating psychologist" responsible for your care, you are "the client" (yourself or the child or adolescent you are organising services for), and Changes Psychology (trading as Paperless Admin) 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 - The Psychology Spot 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 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 you or your child with another professional or person, we need written consent from you to approve this sharing of information. 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. Confirming your first appointment booking - To confirm the first session booking, all new clients consent to completing the Claiming, Consent and $25 booking deposit (that will be $25 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 $25 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 Medicare and private pay - missed appointments, reschedules and cancellations If you cannot attend, would like to reschedule, or need to cancel your appointment; you need to give a minimum notice of 24 hours by phone, text or email. If you don’t provide 24 hours notice, on the first time you will receive an email reminder. If the same happens again, your stored card will be deducted the full session fee for the missed appointment. No rebates are paid by Medicare for missed appointments. NDIS guidelines for late cancellations, or if you do not attend an appointment If you cancel late or do not attend an appointment, we will invoice 90% of the session fee for the appointment. A late cancellation is anything less than 2 business days’ notice.

8. The fees for all Medicare and private pay sessions are: 50 minute session standard fee = $165, Full-time student fee = $135, Centrelink Concession card holders that are on Centrelink benefits = $115. 25 minute session standard session fee = $100, Concession rate = $75

9. Medicare rebates for clients that have a current have a Mental Health Care Plan referral from your doctor. For 50 minute appointments, a Medicare rebate of $86.15 applies. For 25 minute appointments, a Medicare rebate of $61.05 applies. You can claim up to 10 Medicare rebated sessions per calendar year. You need to pay the full fee on the day and our healthcare management system will process the rebate for you, which is received in your bank account the following day or the day after. . Payment for sessions needs to be received before Medicare rebates, Private Health or NDIS self managed Invoices are processed.

10. 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 The Psychology Spot)

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

The Psychology Spot Claiming and Consent form – to be completed by clients to collect their claiming information

Disclaimer and Consent