NEW PATIENT INTAKE FORM

This form is used to keep relevant records of clients and is to be completed before your first session.

This information is confidential and will only be used for reference by your psychologist.

General Information

First name *

Surname *

Date of birth *

Email Address

Home phone

Mobile phone

Would you like to receive TXT reminders for your appointments? *

YESNO

Address *

Suburb *

Postcode *

Medicare Number

Medicare Reference Number

Medicare Expiry date (choose last day of the month)

Do you have a Mental Health Plan?

YESNO

Please upload your Mental Health plan

Browse

Online claiming: Does Medicare have your bank details to process your rebate?

YESNO

Name of referring doctor

Name of referring clinic

Please Note: If we process an online claim for you and you have not registered your bank details with Medicare you will be sent a Cheque after 3 weeks to the address Medicare have in their system. If you are unsure please ask reception to give you an invoice which you can take to a Medicare Service Centre and you can claim your rebate there.

Emergency Contact Information

Emergency contact

Phone

Emergency contact’s relationship to you

Work Information

Occupation

Health Information

In a few words please explain why you are seeking counselling.

Do you have any history of mental / nervous health issues (e.g depression, anxiety, psychosis etc)

Have you seen a psychologist / counsellor in the past for these conditions?

YesNo

A more comprehensive mental health history may be taken at a later stage by your psychologist.

Please list any medications you are currently taking (skip to next question if none)

Medications

Dose

In case of an emergency do we have your permission to call an ambulance?

YesNo

Source of referral

Consent Form

Psychological Service

As part of providing psychological therapy to you our psychologist needs to collect and record personal information from you that is relevant to your current situation. This information forms a necessary part of the psychological assessment and treatment that is conducted. You do not have to give all your personal information but withholding details may impact on the quality of the psychological service able to be provided to you where relevant information is not disclosed.

Purpose of collecting and holding information

The information gathered as part of the assessment, diagnosis and treatment of the client’s condition is used to decide the best path and interventions for the psychological therapy. This information is seen only by your psychologist. The information is retained in order to document what happens during sessions and enables the psychologist to provide a relevant and informed psychological service.

Access to Client Information

At any stage, you, as a client, are entitled to access the information about you kept on file; unless relevant legislation provides otherwise. Please ask/ discuss with your psychologist for the appropriate forms for access.

Confidentiality

All personal information gathered by the psychologist during the provision of the psychological service will remain confidential and secure except where:

It is subpoenaed by a court.
Failure to disclose the information would place you or another person at serious and imminent risk.
Your prior approval has been obtained to:
- provide a written report to another professional or agency. eg. a GP or a lawyer.
- discuss the material with another person, eg. a parent or employer.
Where disclosure is otherwise required or authorised by law.

Fees

The cost of a 50-55 minutes consultation is $200 payable at the beginning of the session by either card or cash. Please note cash can only be accepted where correct money is given as we do not carry change.

Cancellation Policy

If for some reason you need to cancel or reschedule the appointment, please give at least 24 hours notice. Notice given with less than 24 hours may attract a $100 cancellation fee.

Please Note: If, after reading this page you are at all unsure of what is written, please discuss it with the psychologist.

I have read and understood the above Consent Form. I agree to these conditions for the psychological service provided by Centre for Emotion Focused Practice.

*

I confirm that above information I have provided is true, complete and accurate. *

I have read and understood the Privacy Policy of Centre for Emotion Focused Practice for the management of the clients’ information. *

Signature

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Date