New Client Intake Form

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Client Registration Form

PATIENT DETAILS

First Name *

Last Name *

Preferred Name *

Date of Birth *

Gender *

Occupation *

English is a Second Language *

YesNo

ATSI

AboriginalTorres Strait IslanderNone of the Above

If English is your second language, what language is spoken at home

Home Phone

Mobile Phone *

Work Phone

Email

Address *

City / Suburb *

State *

Postcode *

Have you had counselling before? *

If so, how long ago? Was it for this same issue? *

NEXTOF KIN CONTACT DETAILS

Name *

Address *

Postcode *

City / Suburb *

State *

Home Phone

Mobile Phone *

Email

Work Phone

Best way to contact your next of Kin

Home PhMobile PhWork Ph

REFERRING DOCTOR TO US

Referring Doctor’s Name

Address

Family Doctor/ Regular General Practitioner Name (if different to referring doctor)

Address

MEDICARE

Do you use a different name in your medicare card? *

YesNo

If you use Alias please write the Alias name & surname

Medicare First Name

Medicare Surname

Medicare Card No. (no spaces and include the number next to your name) *

Expiry

Medicare Address (if different to your residential address)

PRIVATE HEALTH INSURANCE

Do you have private Medical insurance

YesNo

Provider

Membership No.

Expiry

PENSION / HCC/DVA Card

Do you have an aged pension card, healthcare card or a DVA card *

YesNo

Card Type

HCCPension

Card No.

Expiry(mm/yyyy)

DVA No.

ADDITIONAL INFORMATION

Do you drink alcohol? If so, how much?

Do you use recreational drugs? If so, what and how often?

SIGNATURE AND ADDITIONAL INFORMATION

By ticking this box, you state that you have read the information regarding Confidentiality, Consent to Telehealth, Consent to have your session Bulk-billed, and Other sections.

CONSENT INFORMATION EXPLAINED
Disclosure of personal information

Personal information gathered as part of this service will remain confidential except when: it is subpoenaed by a court; or

failure to disclose the information would place you or another person at serious risk to life, health, or safety; or your prior approval has been obtained to provide a written report to another professional or agency. e.g., a GP or a lawyer; or

discuss the material with another person, e.g., a parent, employer, or health provider; or disclose the information in another way; or you would reasonably expect your personal information to be disclosed to another professional or agency (e.g. your GP), and disclosure of your personal information to that third party is for a purpose that is directly related to the primary purpose for which your personal information was collected; or disclosure is otherwise required or authorised by law.

TELEHEALTH CONSULTATIONS

Where appropriate, the service may be provided by telephone or videoconferencing. You are responsible for the costs associated with setting up the technology needed so you can access telehealth services. Victoria Walters of Achieve Counselling Service will be responsible for the cost of the call to you and the cost associated with the platform used to conduct telehealth services.

To access telehealth consultations, you will need access to a quiet, private space; and the appropriate device, i.e. smartphone, laptop, iPad, or computer, with a camera, microphone and speakers; and a reliable broadband internet connection.

The privacy of any form of communication via the Internet is potentially vulnerable and limited by the security of the technology used. To support the security of your personal information, this practice uses CorePlus, which complies with Australian online security and encryption standards.

Limitations of telehealth

A telehealth consultation may be subject to limitations such as an unstable network connection which may affect the quality of the psychology session. In addition, there may be some services for which telehealth is not appropriate or effective. Your psychologist will consider and discuss with you the appropriateness of ongoing telehealth sessions.

BULK BILLING CONSENT

I, (the patient) agree to the assignment of the Medicare benefit directly to the health professional (bulk billing), Victoria Walters of Achieve Counselling Service. This agreement will remain valid for the term of the Mental Health Care Plan that I have been given by my doctor.

Privacy note: Your personal information is protected by law, including the Privacy Act 1988, and is collected by Services Australia for the assessment and administration of payments and services. This information is required to process your application or claim. Your information may be used by the agency or given to other parties where you have agreed to that, or where it is required or authorised by law (including for the purpose of research or conducting investigations into my condition). You can get more information about the way in which the agency will manage your personal information, including our privacy policy, by contacting Victoria Walters.

OTHER

I may offer a basic Psychological Screening Test (if required). Results will need to be confirmed by a Clinical Psychologist. No major psychological testing will be conducted.

I do not provide forensic psychological services, including writing court documentation/reports, child custody, or family issues. If subpoenaed by a court of law, only all currently existing documentation will be provided as requested in the subpoena.

Due to the time required to prepare them, letters to anyone other than your referring doctor will cost $110 (GST inclusive), payable in advance.

Cancellation or failure to attend a booked appointment without giving 12 hour's notice of non-attendance will incur a fee. As a reminder, you will get a text message the morning before the appointment.

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