Consent form

Welcome to Body Mind Soul Clinic.
All Information that you provide us is strictly confidential.

* Indicates required field

Salutation *

Name *

First

Last

Date of Birth *

Address *

Preferred Name *

Suburb *

Post Code *

Telephone *

Email *

Medicare Card Number (10 numbers) *

IRN (Individual Referrence Number) *

Expiry Date *

Is there any Custodial Issues that we should be aware of? *

Yes No

If this form is being filled out for a minor, parents, please supply your details for assisting in claiming for your child.

Parent/Guardian's Name 1 *

Relationship to the child *

Date of Birth *

Phone *

Email *

Medicare Number *

IRN (Individual Referrence Number) *

Expiry Date *

Parent/Guardian 2 *

Relationship to the child *

Date of Birth *

Phone *

Email *

Medicare Number *

IRN (Individual Referrence Number) *

Expiry Date *

Do you agree that if necessary we can call Medicare on your behalf to request basic information relevant to our services? *

Have you seen another Psychologist this year? *

If Yes, then how many sessions? *

Therapeutic Service
As part of providing a therapeutic service including counselling to you, our Clinicians will need to collect and record personal information that is relevant information in relation to you. This information is a necessary part of the treatment that is conducted. This applies to all services, whether this be face to face or Telehealth appointments.

Confidentiality
All personal information gathered by the clinician during the provision of the counselling service will remain confidential and secure except when:

If there is any indication of harm to yourself;
Harm to someone else;
Harm to a child;
We are subpoenaed by law;
To inform your referring GP to treatment and progress;
Your prior approval has been obtained to:

a) Provide a written report to another professional or agency, eg insurance company or lawyer
b) To discuss the material with another person, eg parent or employer.

Fee Structure
Our standard fees are as follows:
Clinical Psychologist $200 (medicare rebate $126.50 and out of pocket $73.50)
General Psychologist $160 (medicare rebate $86.15 and out of pocket $73.85)

The Australian Psychological Society's recommended consultation fee is $253 for a 45-60 min. session.

You are only eligable for Bulk Billing if you are experiencig extreme financial hardship. If your GP has requested Bulk Billing, your fee will be determined with your Therapist on your first appointment depending on your financial circumstances and whether you fall into the Bulk Billing category.

If your sessions are being paid for by a third party, please provide their detais here.

If you feel you are experiencing financial hardship, then tick this box. This will flag to the Clinician to discuss further your current situation. *

Yes

Third Party Group *

Phone Number of Contact *

Contact person *

Case Number *

Account Details for Direct Deposit of Medicare Rebate

All account and credit card information is held in confidence.

Name Bank Account is held in *

BSB Code *

Account No *

Cancellation Policy
If you need to cancel or postpone your appointment, please give more than 2 business days notice so we can allocate the appointment to another client. If we do not receive the minimum of 2 business days notice, a late cancellation fee of $80 is payable to cover the cost of the Clinician being available to you. A fee of $100 will be chargerd for all NO SHOWS to an appointment. If our Client Management System hasn't debited your card within 24-48 hrs of late attendence or NO SHOW, the fee must be paid on or before your next visit.

Please add our Credit Card Details here

A no show or late cancellation fee will be charged if you do not attend your appointment

Name on Card *

CCV *

Card Number *

Expiry Date *

Please confirm that you understand our cancellation/missed appointment fee. If you have two no shows or two late cancellations, we reserve the right to cancel future appointments. *

Yes

Gold Coast Primary Health Network or ATAPS clients Confidentiality Information

I consent to my information being provided to the Gold Coast Primary Health Network and to the Department of Health to be used for statistical and evaluation purposes' designed to improve mental health services in Australia. I understand that this will include details about me such as date of birth, gender, and types of services I use, but will not include my name, address or Medicare Number. I understand that my information will not be provided to the department of Health if I do not give my consent.

Consent *

Yes No

Date of reading this *

I have read and understood the above mentiond guidelines and I agree with the psychological service provide and the associated fee structure I am required to pay. Should I have any questions or don't understand the above, please talk this over with your treating therapist. *

Yes

Submit

Welcome to Body Mind Soul Clinic.
All Information that you provide us is strictly confidential.

If this form is being filled out for a minor, parents, please supply your details for assisting in claiming for your child.

Account Details for Direct Deposit of Medicare Rebate

Please add our Credit Card Details here

Gold Coast Primary Health Network or ATAPS clients Confidentiality Information

Our Services

Company

Welcome to Body Mind Soul Clinic. All Information that you provide us is strictly confidential.

If this form is being filled out for a minor, parents, please supply your details for assisting in claiming for your child.

Account Details for Direct Deposit of Medicare Rebate

Please add our Credit Card Details here

Gold Coast Primary Health Network or ATAPS clients Confidentiality Information

Our Services

Company

Welcome to Body Mind Soul Clinic.
All Information that you provide us is strictly confidential.