PERSONAL INFORMATION FORM FOR DR KRISTINE MERCURI

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.

First name *

Surname *

Date of birth *

Best contact number where we can leave a message *

Email Address

Occupation

Address *

Suburb *

Postcode *

Medicare Number

Medicare Reference Number

Medicare Expiry date (choose last day of the month)

Do you have a referral from your GP?

YESNO

Referral already received?

YESNO

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

YESNO

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.

Please give details of any Allergies you have

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

Medications

Dose

If you have a local Dr who was not your referring Dr, please give details

Next of Kin

Phone

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

YesNo

Please read and sign the following - Thank you.

Consent Form - Dr K. Mercuri

Psychological Service

As part of providing psychiatric treatment to you, Dr Mercuri needs to collect and record personal information from you that is relevant to your current situation. This information forms a necessary part of the psychiatric 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 psychiatric 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 psychiatric treatment. This information is seen only by Dr Mercuri. The information is retained in order to document what happens during sessions and enables Dr Mercuri to provide a relevant and informed psychiatric 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 Dr Mercuri for the appropriate forms for access.

Confidentiality

All personal information gathered by Dr. Mercuri during the provision of the psychiatric 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 your first session, generally an hour's duration, is $353.20. Medicare Rebate $237.45. Fees are payable at the end 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.

Subsequent appointments are 45 mins. Fee $286 Medicare Rebate $167.55

Cancellation Policy

If for some reason you need to cancel or reschedule the appointment, please give at least 48 hours' notice. Notice given with less than 48 hours may attract a full cost cancellation fee.

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

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

*

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

Signature

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Date