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

a) Adult Client
b) Adolescent Client (Amy only sees young people 12 and above)

Adult client NAME*

Salutation First Last Gender

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

Adolescent or Adult child's Name*

Salutation First Last Gender

Adolescent or Adult child's Date of Birth (eg 11/10/2002)*

It is a conflict of interest for Amy to see individuals who are closely linked, ie, family, friends, partners. Do you know of any close friends or family members that currently see, or have seen, Amy?*

No I don't - continue to complete this form
Yes I do - Unfortunately, Amy will not be able to see you

Amy’s office is up one flight of stairs in a building without a lift. Is this ok with you?*

Yes - I am fine to walk up the stairs
No - I have mobility issues. ACTION required - Please email us and we can organise a room

Your Email Address*

Mobile Number (for sms session reminders)*

Your next of Kin/Emergency Contact Name*

Your next of Kin/Emergency Contact Phone number (mobile preferred)*

How did you hear about Serendipity Psychology?*

How will you claim a REBATE*

Medicare - a Mental Health Plan will be used
Private Health Insurance
Workcover Insurance (IMPORTANT - Email us your GP referral )
DVA - Department of Veteran Affairs is paying
No Rebate - but a paid invoice to be emailed
NDIS funding

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

Self Managed (we take payment off your card and send you an invoice after each session to claim from the NDIS)
Plan Managed (we send invoices to your plan manager)

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

Name of your plan manager organisation that manages your NDIS invoices*

Accounts email address of the plan manager organisation that pays your invoices*

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

Private Health Membership Number*

Name of the Insurance Company (eg Workcover QLD or other insurer)*

Insurance Claim Number*

Case Manager Name*

Case manager email address*

DVA Gold or White card number*

ADULT Medicare Card number*

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

Adolescent or Adult child's Medicare Card Number*

NUMBER in front of the Adolescent or Adult child's name on the MEDICARE CARD (eg 1, 3)*

Address REGISTERED WITH Medicare*

Address Suburb Postcode

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)

Address*

Street Address Suburb Postcode

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

Disclaimer and Consent to Terms and Conditions

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

1. AGREED PARTIES - Dr Amy Manuel of Serendipity Psychology is your treating "psychologist" responsible for your care, you are "the client" (yourself, the child, adolescent or another adult you are organising services for), and Changes Psychology (also known as Paperless Admin) is the admin and billing service "provider" that is only responsible for processing clients' bookings, billing and client administration on behalf of your treating psychologist. By signing this agreement, you are agreeing to the provision of services under this arrangement.

2. PRIVACY - Paperless Admin and Serendipity Psychology take 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 in order to facilitate appointments with your psychologist and to manage payments including Medicare and health insurance rebates. 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. LEGAL SUPPORT - 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 the requirements of the plan. We will not be responsible for sharing information with other parents or stakeholders.

5. INFORMATION SHARING - We need written consent from you to approve sharing of information with a third party. 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 the external agency funding the appointments, regarding your treatment progress. By agreeing to these terms and conditions you agree to this information sharing policy.

6. NEW CLIENTS - To confirm the first session booking, we need all new clients to complete this Claiming and Consent form before their first session

7. PAYMENT OF SESSION FEES - Payment of your $160 session fee will be required at the end of every session via EFTPOS terminal (unless prior arrangement has been made for a third party to pay your fees).

8. Medicare rebates - If the client is referred on a Medicare-rebated Mental Health Care Plan to Dr Amy Manuel by their GP, the Medicare rebate will be $126.50. Clients are only eligible for Medicare rebates if they have provided a GP referral letter requesting services and a mental health treatment plan. We collect, use and (where appropriate) store this information in order to facilitate appointments with your psychologist and to manage payments including Medicare and health insurance rebates. Medicare rebates are processed after the full session fee has been successfully received.

9. CANCELLATION POLICY - No show or Cancellations on the same day of the appointment = $160. Cancellations the day prior, but less than 24 notice = $55. You need to cancel at least 24 hours prior to the session to avoid cancellation fees.

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

Consent & Client Claiming form

Disclaimer and Consent to Terms and Conditions