NEW PATIENT (Child - Adolescent) 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.

Young Person's Information

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Parents/Guardian Information

Person 1 (e.g. Mother)
Person 2 (e.g. Father)

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.


Very Brief Child/Adolescent History

Please list any medications that your child/adolescent is currently taking. (Skip to next question if none)

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

Source of referral


Consent Form for Child / Adolescent

(to be completed by parent / guardian)

This document will inform you about how we manage the information that you and/or your Child/Adolescent disclose to your psychologist.

Psychological Service

As part of providing psychological therapy to you/your child, your treating psychologist needs to collect and record personal information from you that is relevant to you/your child's 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:

  1. It is subpoenaed by a court.

  2. Failure to disclose the information would place you or another person at serious and imminent risk.

  3. 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.

  4. Where disclosure is otherwise required or authorised by law.

Exchange of Information with Other Professionals

There are times when consulting with other treating health professionals may assist in a more comprehensive assessment and treatment plan for you/your child. Your psychologist may ask for your consent to speak with any relevant treating professionals and will ask that you either sign a form or provide written consent for this to occur.

If you are accessing psychology services through a Medicare Mental Health Care Plan, Medicare requires us to provide the referrer (ie, GP, Paediatrician, Psychiatrist) with a brief summary of your/your child's treatment progress and we assume consent as part of you signing this form.

Consultation Fees

The cost of a child/adolescent 50-55 minutesconsultation is $220 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.

Please note that rebates are only available if the correct mental health plan has been received by our offices.

Parent sessions are not normally covered by mental health plan and are also $220.

If your child/adolescent will be attending and you will not be present to arrange payment, you are encouraged to arrange payment ahead of time by calling our reception number between 10 am and 5 pm.

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.

  • No Show to your scheduled appointment will incur full fee charge and no rebate is available.

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