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

Client's Name*

First Last

Client's Date of Birth (eg 11/10/2002)*

Adult client NAME*

First Last

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

Name of Emergency/Primary Contact person for Child (eg Parent 1)*

Mobile Number of Emergency/Primary Contact (NOTE: sms appointment reminders will be sent here)*

Name of Secondary Contact person for Child (eg Parent 2)*

Mobile number of Secondary Contact*

Email Address (to send invoices and correspondence)*

Mobile Number (for sms appointment reminders)*

Full Name of Clients Emergency Contact*

Mobile Number of Emergency Contact

How did you hear about Sunlight Psychology?*

Google/Searching Online
A friend
GP
Paediatrician
Occupational Therapist
Speech Therapist
School staff (Guidance Officer/teacher)

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

NDIS funded clients - Services provided by your psychologist will be supplied as one or more of the reasonable and necessary supports specified in your NDIS Plan (under subsection 33(2) of the NDIS Act).

Please email a copy of your NDIS Plan to info@sunlightpsychology.com.au

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*

ADULT Medicare Card number*

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

CHILD 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

Home address of the client*

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)

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 Christina'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

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

Brief reason for the referral and therapy

Disclaimer and Informed Consent

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

1. Parties who access your personal information

“You” – the client receiving therapy, or the parent/guardian/person arranging services for a child, adolescent, or another adult.
Your treating “psychologist” will be either Ana Catton, Christina Birch or our Provisional Psychologist Lyn O'Connor, of Sunlight Psychology who will be responsible for your assessment, treatment and clinical care.
Administrative/billing “provider” – Changes Psychology manages bookings, billing, and Medicare/private health claims on behalf of your psychologist.
Practice “software” – including Halaxy, Outlook, Heidi and other secure software applications used to deliver our services.
Collectively, we refer to all parties involved in your care (except you) as “we”.
By signing this document, you acknowledge the roles of your psychologist, the provider and the software used to deliver your care.

2. Informed consent

Your psychologist will explain the purpose of treatment, how it works, the potential benefits and risks, and any alternatives.
You are welcome to ask questions, request changes, seek a second opinion or withdraw consent at any time by speaking with your psychologist or emailing us.
Consent may be reviewed if the objectives of treatment, risks, fees or involvement of other parties change.
You may withdraw consent for us to share your information at any time; however, doing so may limit the services we are able to provide or affect your eligibility for rebates.

3. How we use your personal information

We operate like a virtual clinic office, collecting and managing personal and medical information provided by you and your psychologist.
This naturally includes sensitive health information.
We collect, use and (where appropriate) share this information to facilitate appointments with psychologists.
We collect, use and (where appropriate) share this information to manage payment, Medicare and insurance claims.
We collect, use and (where appropriate) share this information to maintain accurate records of your appointments.
We manage your information in accordance with industry standards and all applicable laws.
Your client records are stored securely online in Halaxy using encrypted and access-controlled systems.
Changes Psychology uses staff in Australia and the Philippines who follow strict confidentiality requirements.
Halaxy stores and processes data in Australia and Ireland using secure, compliant systems.

4. Confidentiality and limits to confidentiality

All personal information gathered during the provision of psychological services will remain confidential and securely stored.
Confidentiality may be breached if information is subpoenaed by a court.
Confidentiality may be breached if your psychologist believes you pose an immediate risk to yourself or others.
Confidentiality may be breached if your prior approval has been obtained to provide a written report to another professional or agency (e.g. GP or lawyer).
Confidentiality may be breached if your prior approval has been obtained to discuss relevant information with another person (e.g. parent or employer).
Confidentiality may be breached if a regulatory or funding body requests information.
Confidentiality may be breached where disclosure is required to comply with legal, ethical, professional or mandatory obligations.

5. Information sharing

Written consent is required for your psychologist to share or receive information with any third party.
This includes ex-partners, teachers, health professionals or other individuals.
We are not responsible for implementing the requirements of parenting plans.
If you intend to claim Medicare rebates, summary reports must be provided to the referring GP, Paediatrician or Psychiatrist.
If another organisation is funding the service, reports must be provided to meet funding requirements.
By agreeing to these terms, you consent to this necessary information sharing.

6. Peer supervision

Your information may be shared in a de-identified manner during peer supervision sessions.
This supports psychologists to maintain best practice and high-quality care.
You may advise your psychologist if you do not wish for de-identified information to be used in this way.

7. Accessing your Client Information

You have a general right to access your records, subject to legal and privacy exceptions.
You may request access to your records.
A young person of sufficient maturity must consent to disclosure of their records to parents.
A young person may withdraw consent at any time.
Requests to view records must be made in writing with two weeks notice.
Access options will be discussed with you once a request is received.
Please allow 21 days for arrangements to be made.

8. Consent for note-taking software

Your psychologist uses an AI digital scribing system called Heidi Health.
The system supports accurate and efficient note-taking.
Heidi provides a summary that is reviewed by your psychologist before saving.
Heidi Health complies with Australian Privacy Principles and AHPRA standards.
You may opt out of the use of this system at any time.
Further information is available at https://trust.heidihealth.com.

9. Consent for telehealth sessions

Services may be provided via telephone or videoconferencing where appropriate.
Internet-based communication carries some level of security risk.
You are encouraged to attend telehealth sessions in a private and secure location.

10. Session fees and payment

Session fees are confirmed in your booking confirmation email.
Fees may increase periodically to cover increased practice costs.
A $1 deposit is required to confirm the first session booking.
Your card details will be securely stored in the NAB Transaction system.
All payments appear as ‘Changes Psychology’ on bank statements.
Payments and Medicare rebates are processed after the session.
DVA sessions are claimed directly through DVA.
NDIS session fees follow the NDIS Price Guide.

11. Cancellation policy and session attendance

Consistent attendance supports progress toward treatment goals.
Appointments should only be booked if you intend to attend.
Full fees apply to non-attendance.
Cancellations with less than 24 hours notice incur the full session fee.
NDIS late-cancellation charges follow NDIA guidelines.
To avoid charges, admin must be notified at least 24 business hours prior.
Appointments may be changed to telehealth as an alternative.
Session time may be used for reports or research at your request.
The $1 deposit is retained if the first session is cancelled.
SMS and email reminders are provided as a courtesy only.
By completing this form you agree to the Terms & Conditions and Privacy Policy.

Note Taking

I consent to Sunlights use of the Heidi Digital scribing system

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

NOTE: $1 session fee credit for Sunlight Psychology will be deducted now to confirm your booking. Your card details being stored with NAB for future billing. Transaction Reference will be 'CHANGES PSYCHOLOGY NORTHGATE'*

Price:

Press submit and Proceed to the NAB Payment Page to enter your credit or debit card details to pay the $1 session fee credit to confirm your first session (your card details will be stored with NAB and used for future session fee payments)

$ 0.00

Sunlight Psychology Claiming, Consent and $1 session credit towards your first session – to be completed by all new clients to confirm their first session booking.

Disclaimer and Informed Consent