Fields marked * are required.

Patient Personal Details

Title... * Mr Mrs Ms Miss

Given Names: *

Surname: *

Date of Birth: *

Address:

Postal Address (if different from above):

Phone: *

Email: *

Your Occupation:

Relationship Status:
Single   Married   Defacto   Separated   Divorced

Next of Kin:*

Name
Relationship
Phone

Medicare Details:

Payment Details

Payment is required at the time of consultation. In the event this may not be possible, invoices for services rendered should be paid within fourteen days. Where payment has not been made within the allotted time, the details provided below will be used to pay the outstanding amount.

Are you the person responsible for the payment of the account?
Yes   No

Credit Card Details
Visa   Mastercard

Name on Card:

Card Number:

Expiry:

Service Agreement & Consent

To ensure the welfare, satisfaction and protection of privacy for all our clients, psychologists operate in accordance with the following service agreement and consent terms. Please carefully read and sign the following policy. If you have any questions about this service agreement, please feel free to discuss these with your psychologist.

Psychological Service

As part of providing psychology services, your psychologist will need to collect and record personal information from you that is relevant to your current situation. This information will be a necessary part of the psychological assessment and treatment that is conducted.

Confidentiality

Privacy and confidentiality for our clients is a priority. We insist that this confidentiality be extended to all our clients. If you know another family who uses our service, please protect their privacy. Protection of your privacy is also ensured in this way.

All personal information gathered by your psychologist is treated as confidential and secure. Apart from communicating with your referring GP or Medical Specialist (providing thank you letters for referrals and update reports), we will not disclose any information about you or your family to any other agency or person without your permission unless:

a. Mandated by a court of law;

b. We feel there is a threat to the safety or integrity of yourself, someone in your family, your psychologist, or to someone else. In such an unlikely event, every effort will be made to discuss this with you prior to any disclosure;

c. Your prior approval has been obtained to communicate with another professional/agency (e.g. GP or lawyer), organisation (e.g. your child's school) or person (e.g. a parent or employer).

For service quality, supervision purposes, and to ensure the safety and security of both clients and psychologists, clinical sessions may be recorded via audio and/or video means. Any recording is treated as strictly confidential. Written permission will always be sought prior to the use of such recordings for any other reason, excluding legal proceedings.

Evaluation

Assessment information may be utilised for clinical research and service evaluation purposes. All identifying information and names will be omitted from any such usage, and will remain completely confidential. You have the right to withdraw participation in research at any time.

Fees

All fees are to be paid at the time of consultation (Cash, Cheque, and EFTPOS/Credit Card Available).

Standard rates for Clinical Psychology		Standard rates for General Psychology
One Hour Consultation $171.15		One Hour Consultation $132.25
Half Hour Consultation $112.25		Half Hour Consultation $87.95

*All consultations must be scheduled in advance. Telephone consultations also attract standard consultation fees. On occasion, fee amendments may be made during the year.

Cancellation Policy

Family Challenge Psychology Clinic is usually fully booked. Last minute cancellations or 'no-shows' mean that others miss out. As such, a cancellation policy has been established. If for some reason you need to cancel or postpone your appointment, please provide at least 24 hours notice. Should an appointment be cancelled within 24 hours of the scheduled time, a cancellation fee of $55 (GST Incl.) will apply. If the cancellation is due to a genuine emergency or family/child illness, the cancellation fee will be reduced to $33 (GST incl.).

Disclosure to Specific Third Party

Under a Medicare Mental Health Care Plan, it is a requirement for our service to communicate with your referring GP or Specialist (e.g. provide thank you letters for referrals and update reports). This form of communication (including emails, telephone calls, and/or letters) is provided without charge.

Declaration

I have read, understood, and agree with the Family Challenge terms of service.

Fees and Compensation being charged to Credit Card

I hereby commit to pay all fees and compensation where required. I irrevocably authorise Family Challenge to debit my credit card account with the amount of any fees or charges payable by me under this agreement.

Default Action

I acknowledge that if any fees or compensation remain outstanding for any reason Family Challenge may, without prior notice to me,

a. Debit my credit card for the due amount at any time without additional notice

b. Report that fact to the Credit Reference Association of Australia or other default registry, which may affect my credit rating in the future

c. Refer any outstanding fees to a third party debt collector.

I understand that if Family Challenge makes a report on me to the Credit Reference Association of Australia, I may not be able to obtain finance and credit until I have paid Family Challenge all that is due.

I agree *

Enter the security code shown: *