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

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

Parent/Carer 1 Name*

First Last

Parent/carer 1's relationship to the child (or the relationship of the parent organising sessions) to the child client/s*

Biological parent
Step parent
Foster parent

Parent/Carer 1's Email Address*

Parent/Carer 1's Mobile Number (for sms appointment reminders)*

Parent/Carer 2's Name (if they will be involved separately)

First Last

Parent/carer 2's relationship to the child client/s

Biological parent
Step parent
Foster parent

Parent/Carer 2's Email Address

How did you hear about Southern Highlands Psychology?*

How will you claim a REBATE*

Medicare - a Mental Health Plan will be used
Private Health Insurance - an invoice to be emailed for claiming
No Rebate - but a paid invoice to be emailed
NDIS funding

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)

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*

ADULT's Medicare Card number*

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

CHILD's 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 already have a Mental Health Treatment Plan (MHP) or Psychiatrist/Paediatrician, we need you to enter some information from it below so we can process your rebate faster. If you don't haev a MHP or don't have a copy with you, please leave the following boxes blank. IMPORTANT - when you get the MHP please take a picture of your MHP or referral on your phone/scan it and email it to us. Bringing it to your session will mean the rebates take longer to process.

Your referring GP's (or Psychiatrist's/Paediatrician's) first and last names

Your referring GP's (or Psychiatrist's/Paediatrician's) Medicare provider number (it is on your Mental Health Plan or referral, and has 7 numbers + 1 Letter - eg 3485687T)

Fax number of the GP practice with 02 in it

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)

Please briefly describe your concerns about your child

Please briefly describe your concerns or issues you'd like support with*

Does your child have any medical conditions? If yes please describe below

Does you have any medical conditions? If yes please describe below

Does your child take any prescribed medication? If yes, please provide details below

Does you take any prescribed medication? If yes, please provide details below

What school does your child attend?

What year is your child in?

Did your child attend any previous schools?

Do you have any concerns about your child's learning? (eg difficulty with reading, spelling, numbers

Has your child ever seen a psychologist before? If yes, please provide details below: (eg child’s age at the time, name of professional, reason for referral)

Has your child undergone any assessments before (e.g. cognitive, occupational therapy, speech pathologist)? If yes, please provide details below (and bring any reports to your first appointment):

Southern Highlands Psychology 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. Dr Andrew Franland of Southern Highlands Psychology is 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 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 - Southern Highlands 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. Parenting plans - if there is a parenting plan in place we require the parent or person engaging the treatment to meet all requirements of the plan.

5. Information sharing - If you would like the psychologist to share and collect information about your child with your ex-partner, you child's teacher, or any other persons, we need written consent from you to approve this sharing of information with each individual. 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 and the details outlined in our Privacy Policy and in this Information, Consent and Payment form.

6. Confirming your first appointment booking - To confirm the first session booking, all new clients are required to complete the Information, Consent, and Payment Form via the online form and payment portal link that will be emailed to you within 48 hours of receiving the confirmation email. Your card details will be processed for the $1 deposit only and your card details stored securely encrypted within the NAB (National Australia Bank) Transact system and be used to deduct all future session fee payments and all other fees when they are owed

7. Cancellation Policy - If you wish to cancel or re-schedule a session without cost, we require more than 24 hours notice. A cancellation fee equivalent to 50% of the standard fee may be charged if you fail to attend an appointment without prior notice or cancel on the day of the appointment to cover some of the impact of this cancellation.

8. The fee for a standard therapy session is currently $180 and may increase yearly to cover practice costs. This fee covers each 50-minute session, brief phone consultations, liaising with referring professionals, and general administration. Payment for sessions needs to be received before Medicare rebates are processed. All session fee and cancellation fee payments will be taken via our online payment system NAB Transact after sessions occur, direct deposits are not a payment option. All payments will show up on your credit or debit card statement/online banking with the payment reference 'Changes Psychology Northgate' (NOT Southern Highlands Psychology)

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

Information and Consent Form

Southern Highlands Psychology Terms and Conditions