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 Stella Bowring Psychology?*

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

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)*

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

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)

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. Stella Bowring is your "treating psychologist" responsible for your care, you are "the client", 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 - Stella Bowring Psychology 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. Information sharing - If you would like the psychologist to share information about you with other parties it is your responsibility to provide this consent in writing. 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, or Psychiatrist 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.

5. Neither your treating Psychologist, or admin provider, will provide information, reports or documentation for medico-legal or family court related purposes unless we are required to by law, under a subpoena or by a court order.

6.Confirming your first appointment booking (both bulk billing and full fee paying clients) - To confirm the first session booking, all new clients consent to completing the Claiming, Consent and $50 booking deposit. For full fee clients, the $50 will be credited towards the cost of your first session (so $110 will remain out of the full $160 fee and you will get your Medicare rebate of $124.50 paid back to your bank account after that). Bulk billing permitted clients will get the $50 back when you want to end treatment sessions and a cancellation fee does not apply). To pay this $50 please complete this online form and NAB payment portal link 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.

5. Confirming your first appointment booking (both bulk billing and full fee paying clients) - To confirm the first session booking, all new clients consent to completing the Claiming, Consent and $50 booking deposit. For full fee clients, the $50 will be credited towards the cost of your first session (so $110 will remain out of the full $160 fee and you will get your Medicare rebate of $124.50 paid back to your bank account after that). Bulk billing permitted clients will get the $50 back when you want to end treatment sessions and a cancellation fee does not apply). To pay this $50 please complete this online form and NAB payment portal link 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 with less than 48 hours the psychologist will retain the $50 booking deposit. If you wish to cancel or re-schedule an appointment without cost, we require at least 24 hours notice to reschedule via call or email. Unfortunately, session bookings cancelled within 24 hours of the appointment time will attract the full fee of $160 which will be deducted off your stored card.

8. The session fee for all of your Treating psychologist's services is $160 per 50 minute session, and this amount will be deducted in full after every session (minus any credit paid) 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 session fee and cancellation fee payments will be taken via our online payment system NAB Transact within 24 hours of your session being completed. All payments will show up on your credit or debit card statement/online banking with the payment reference 'Changes Psychology Northgate' (NOT Stella Bowring 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*

Stella Bowring Psychology Claiming and Consent form – you need to complete this form to receive your Medicare rebate or Private Health Inovice

Disclaimer and Consent