CLIENT REGISTRATION AND CONSENT – Private Clients

Please include Ms, Mr, Dr, Miss, etc
Please note: you must provide a copy of this referral before you are able to claim any Medicare rebates
FEE STRUCTURE These temporary fees are in line with the NDIS rates and Medicare rebates that apply from 30.3.20 (COVID19 response) and will be revised from time to time with future changes in NDIS and Medicare rates. MEDICARE CLAIMS Clients with a Mental Health Care Plan from a GP, or a referral from a paediatrician, will be able to claim a rebate from Medicare, after paying the fee. A gap of approximately $105 to $120 per session will usually apply. HEALTH FUND REBATES Rebates from your private health fund will be available for most services to clients with extras cover for psychology. Fees for preparing reports are not claimable from health funds or Medicare. PAYMENT Payment on the day is required by EFTPOS, cheque or credit card. HICAPS is available for some Health Fund members at our Opey Ave office. Payment for services at our other office can be paid by direct debit or by credit card by calling our office. You are responsible for paying any gaps, any fees rejected by Medicare or your Health Fund, and any additional expenses incurred in recovering outstanding monies. CANCELLATION 100% of the fee will be charged for appointments not attended or cancelled with less than 24 hours’ notice. For NDIS clients, 100% of the cost of service will be charged with less than 3 days’ notice (see NDIS Terms of Service). PRIVACY OF INFORMATION As a necessary part of providing a psychological service to you/your child, your/your child’s personal information will be recorded and securely stored. This will remain confidential and your/your child’s prior approval is needed to release any information to another professional, agency or family member, or any other person, except when it is subpoenaed by a court of law, or if failure to disclose the information would in the reasonable belief of the psychologist place you/your child or another person at serious risk to life, health or safety, or where the Psychologist has a duty to make a Mandatory Report. In the case of parental separation you are advised to let the child’s other parent know that your child is receiving psychological services, but their consent is not required unless specified in a court order, and any information about your child receiving psychological services cannot be released to another person, including the other parent, without your prior consent or child’s consent if they are old enough to give such consent.
I have read and understood this form, and give consent for psychological services to be provided to me/ my child/my family. I accept the conditions outlined above, and accept that I am responsible for payment of all fees, unless agreed otherwise.
I consent to the release of information and copies of relevant reports to/from
If you are unsure about any information on this form, please discuss with your Psychologist or Jenni Pearce