Select who will be the client (select BOTH a & b if parent & child having sessions or BOTH have Mental Health Plans)*

a) Child/Teenager under 18 for Individual Therapy
b) Adult Client for Individual Therapy
c) Couples therapy

Child/teenagers Name*

First Last

Child/teenagers Date of Birth (eg 11/10/2002)*

Partner 1's Name*

First Last

Partner 1's Date of Birth (eg 11/10/1984)*

Partner 2's Name*

First Last

Partner 2's Date of Birth (eg 11/10/1984)*

Adult client NAME*

First Last

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

Parent Name*

First Last

Your Email Address*

Mobile Number (for sms appointment reminders)*

Next of kin (emergency contact) FULL NAME*

Next of kin (emergency contact) PHONE NUMBER*

Which practice location/s will your sessions be help at (note you can change these later if required):

Kenmore
Jindalee
Toowong
Milton (NOTE- location closing Monday 18/03/19)

How did you hear about Revival Health?*

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
NDIS funding

NOTE re Couples Counselling - Medicare does not allow rebates to be claimed for couples counselling, only for individual sessions not related to couples counselling. However Private Health Insurance can be used. So please choose an option other than medicare above

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

Self managed (we send you an invoice to claim from the NDIS)
Plan Managed (we send invoices to your plan manager)
NDIA/NDIS managed (we claim from the NDIS directly)

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

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/TEENAGER'S Medicare Card Number*

NUMBER in front of CHILD/TEENAGER'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)

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)

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

Terms and Conditions

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

1. Dr Matthew Evans is your "treating practitioner" responsible for your treatment and care, you are "the client" (yourself 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. Please note that for couples’ therapy, the couple’s relationship is “the client” rather than one specific individual. By signing this agreement you are agreeing to the provision of services under this arrangement

2.Privacy - Revival 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 health professionals; 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 practitioner to share and collect information about yourself or other stakeholders e.g. your ex-partner/teacher/OT etc, we need written consent from you to approve this sharing of information with each individual. If you are receiving couples’ therapy, communication between Dr Matthew Evans and an individual from the relationship, without the other person present or with their consent, is avoided were possible, except in situations where there is a risk of harm. 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 for Matt's sessions are collected via eftpos at each completed session. The initial consultation fee (55 mins) is $180, subsequent consultations (55 mins) are $160. If a therapy session exceeds one hour, a proportional charge of $50 per 15 min block may apply. Phone calls or emails that require longer than 15 mins to address will be charged at this rate, including calls to other agencies when requested by the client. Letters and reports are charged at the same rate, based on the time taken to complete them. Matt will collect the full fee at the time of the appointment. If you are getting a rebate through Medicare’s Better Access scheme, you will receive a rebate electronically of $124.50. Insurance rebates and hence the out of pocket expense varies by insurer. DVA and “Altogether You” referrals are bulk billed with no out of pocket expenses.

7. Cancellation Policy - Confirmation texts are sent 72 hours prior to your appointment. If you cancel your session with less than 48 hours notice, Revival Psychology reserves the right to charge $50 as a late cancellation fee. This cancellation fee must be paid prior to new appointment bookings. If you wish to cancel or reschedule an appointment without cost, we require more than 48 hours notice. We reserve the right to refuse booking of future appointments for clients who repeatedly cancel within less than 48 hours. Our cancellation policy is designed to be fair as possible to our clients who need to cancel or reschedule, those clients on our waitlists and our clinicians.

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

Partner 2 listed above needs to sign this themselves (Partner 1 needs to sign in the box above)- 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 Revival Health Clients- complete this form before your first session so we can process your DVA, Medicare Rebate or Private Health claims

Terms and Conditions