Full name of client*

First Last

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

Email Address*

Mobile Number*

Name of Emergency Contact/Next of Kin*

First Last

Emergency Contact Phone Number*

How will a REBATE be claimed for psychology sessions:*

Medicare - a Mental Health Plan will be used
Private Health Insurance (we will email you an invoice to claim)
No rebate will be claimed (we will email you an invoice)
An Insurance company or another organisation will be paying
Workers Compensation Insurance will be paying

Your Home Address*

Address Suburb Postcode

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

Private Health Membership Number*

Client Medicare Card number (10 digit number)*

NUMBER in front of client's name on the MEDICARE CARD (eg 1, 3)*

Address REGISTERED WITH Medicare*

Address Suburb Postcode

Do you want the Medicare rebate paid to the client listed above?

Yes - pay the rebate to the client listed above (into their bank account registered with Medicare)
No - please pay the rebate to someone else (ie the claimant - which may be yourself or their parent for example)

Full Name of the Adult that the Medicare rebate needs to be paid to (the Claimant)*

Date of Birth (DOB) of the Adult Claimant that the Medicare rebate needs to be paid to (the Claimant)*

Is the Adult Claimant's Medicare card number (10 digits on the Medicare card) the same as the child client above

Yes - the Adult claimant's Medicare card number is the same as the child client's
No - the Adult claimant has a different Medicare card number (please type it in the box below)

The Medicare card number (10 digits) of the Adult claimant*

What is the number in front of the Adult Claimant's name on the Medicare card (eg 1, 2 or 3 usually)*

Is your BANK ACCOUNT registered with Medicare (rebates go back to this card, NOT back onto the card you paid with)*

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

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 Renee'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 (if you have this information with you now)

What date is your first or next session with Renee Goosen (Eg 02.06.18) if you have a session booked in

How did you hear about Renee Goosen Psychology?*

I saw her at another practice
GP
Psychiatrist
APS Website
A friend
An organisation recommended her

In summary, what is the reason for your referral or for booking a session with Renee? (if you are willing to share this with Renee before the session)

Terms and Conditions and Consent

1. Renee Goosen, is your "Provider" and treating clinical psychologist responsible for your care, you are "the client", and Changes Psychology is the "admin and billing service provider" that only manages Renee's clients' bookings, billing and client administration.

2. Privacy - Renee Goosen, and Changes Psychology take your privacy seriously. We work like a virtual clinic office, collecting and managing personal and medical information provided by you and your clinical psychologist, which naturally includes sensitive health information. We collect, use and (where appropriate) share 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 industry standards and applicable laws. Our handling of personal information involves storage and processing of some data overseas. For more about privacy, and who to contact if you have questions or complaints regarding privacy, see our Privacy Policy Privacy Policy

3. Provider, or admin and billing service provider, will not provide information, reports or documentation for medico-legal or family court related purposes unless we required to by law, under a subpoena or by a court order.

4. Cancellation Policy - If you wish to cancel or re-schedule an appointment, we require at least 48 hours notice and appointments cancelled within 48 hours of the appointment time will attract a $130 cancellation fee.

5. Payment for appointments will be taken at the time of your appointment. Payment can be made via EFTPOS or cash payment.

To agree to these policies SIGN IN THIS BOX with your finger (on mobile device) or use your mouse*

Consent & Claiming Form for Renee Goosen Psychology- all clients need to complete this form before their first session. This form enables us to process Medicare Rebates or Private Health invoices for you

Terms and Conditions and Consent