Client Registration Form

Adult or child attending therapy (client)

Title *

First name *

Surname *

Sex

Date of Birth *

Preferred name

Adult Client or Under 18 (Child Client) *

Adult ClientUnder 18 (Child Client)

Address *

Postcode *

Suburb *

Email *Used for receipts, appointment reminders, practice updates & communication about therapy

Email for ReceiptsIf different to email provided

Home phone

Mobile phone *We will send sms reminders to this mobile, we recommend a parent's mobile for child clients

Third party/Medicare Funding *Payment is due on the day of service. Please ensure that you have a valid approved NDIS service item, GP referral, EAP referral, DVA, ADF GP referral or insurance claim for your sessions or you may not be eligible for third party payments.

Please provide your claim number/DVA card/Plan manager or other detailsAustralian Defence Force Referrals are sent to us by ADF, provided your appointment was arranged by ADF.

Medicare Card *please provide for future reference regardless of your current intention to make a medicare claim.

Medicare Card Reference No

Medicare Expiry

Occupation *

Relationship status

How did you hear about us? *

Religion

Partner/Parent/Family member attending therapy OR Emergency contact details

Are you attending therapy with someone else? *

I am attending on my ownMy family member/partner or friend is attending with me, we are attending together

Only select my partner/family/friend is attending with me if they are attending your first session with you as we will email them this registration form to complete prior to attending.

Family/Partner/Friend First NameName of family/partner/friend intending to regularly attend therapy with you

Last Name

Mobile

EmailWe will email this registration form to your family/partner/friend so they can complete it.

DOB

Occupation

Medicare Card

Medicare Reference Number

Parent First Name

Parent Last Name

For appointments with minors, we recommend that the parent attends the first or subsequent session so that you can brief the psychologist about your concerns and we can discuss expectations around therapy, progress updates and confidentiality.

Parent Email

Parent Mobile

Parent Medicare NumberPlease note that parent's Medicare Number and DOB required for child claim rebates otherwise rebates default to the bank account registered with Medicare which may be another parent.

Medicare Reference Number

Parent Medicare Card Expiry date

Parent DOB *Parent DOB is required for your child's Medicare Claims

Occupation

Are there parenting orders in place for your child ?

Yes - I will provide the parenting orders at my child's first session and book time to discuss concerns with the psychologistNo parenting orders are in place for my child

Please provide a copy of your parenting orders at the day of your appointment and allow time for the psychologist to review them. Complex matters may require additional time for review

Parental Consent

Check if you declare that the other parent/guardian consents to therapy

Emergency Contact Details

First Name

Last Name

Email

Mobile

Authorised contacts to discuss YOU or YOUR child’s attendance/billing

(please note that if another parent or legal guardian contacts the service we are obligated to provide a treatment update to that guardian)

First Name

Last Name

Relationship

DOB

What to expect at your first visit?

Consultations usually go for around 50 minutes or 75 minutes (depending on booking) Your psychologist will invite you into the consulting room and begin by asking ask you about what you would like help with, your stressors, your personal history, and family and relationships. It usually takes about 3 sessions to clearly identify the concerns and goals for therapy, we recommend you book 4 sessions ahead to keep momentum and secure your preferred time.

Booking sessions ahead

We want to ensure we deliver our service smoothly, responsibly so we can fulfill our duty of care to you so we recommend you book your subsequent appointments 4-6 sessions ahead. This prevents wait times of 3-4 weeks for appointments and ensures that you have more preferential appointment slots.

How many sessions do I need?

The length of therapy is quite variable, and the final decision regarding the length of therapy rests jointly with you and your psychologist. Some people stay for around 6 sessions, while others are in counselling for two or three years or more. Most people need around 13 - 20 sessions to overcome general anxiety, depression or relationship issues. This can vary for more complex issues such as PTSD or OCD.

Confidentiality

All information provided will remain confidential. Limitations to confidentiality are when:

Disclosure is required by law or subpoenaed by a court,
Failure to disclose information would place you or another person at serious and imminent risk as assessed by the psychologist, and
Your written consent has been obtained,
Where you have been referred by a G.P or medical specialist and the information provided is relevant to you treatment.
If you are attending therapy with your partner/family member you agree that relevant information shared within an individual session is free to be shared in joint sessions in due course and acknowledge that you need joint consent to remove/share information from joint sessions.
If your adolescent is attending therapy we will provide treatment update sessions to the guardian but in most cases, therapy is confidential unless risk is indicated.

Fees for letters/statement of attendance

If you require a letter please advise your psychologist at the beginning of the session so that it can be prepared as part of your consultation otherwise additional fees apply.

Late Notice Session Fee Policy

We encourage you to keep your appointments but if there is no way to keep your appointment by video/phone or in-person and you need to change your appointment, please provide at least 48 hours notice so we can offer care to another person and call head office on 08 6555 7786 or email – Do not SMS.

For cancellations/reschedules/non-attendance made with 48hrs notice the fee $150. If we can rebook the appointment, you will not be charged. A portion of late notice fees goes to support the Smith Family Australian Children’s Charity.

PLEASE NOTE: there are no Medicare payments, or TAC or Workcover reimbursements, for late notice fees or missed appointments.

Psychological Privacy Policy

As part of providing a service to you, your psychologist will need to collect and record personal information that is relevant to your treatment. You do not have to give all your personal information, but if you don’t this may limit the services provided to you. Your personal information is gathered as part of your assessment and part of your therapy is kept securely and, in the interests of your privacy, used only by your psychologist and the authorised personnel of the practice (as necessary).

Video and Phone Sessions

Telehealth has been recommended by Australian Psychology governing bodies as a suitable medium to enable vital continuity of care for all clients / patients requiring psychological assessment, treatment and / or support during the current COVID-19 pandemic.

Video Session Privacy and Quality

Your clinician will use a headphones and a private room at the office or home. We recommend you set up your own private, comfortable, well lit space and home/private WIFI connection (not public). Do not allow other parties to be present or record the sessions without informing the psychologist. Transmissions of services could be disrupted by technical failures.

Access to client information

At any stage you are entitled to access your personal information kept on file, subject to exceptions in the relevant legislation. The psychologist may discuss with you different possible forms of access.

Additional sessions, support between sessions and fees

If you require clinician contact between sessions please contact reception to arrange an additional appointment, this can be either an in-person/phone/video call with the psychologist that is billed at the pro-rata sessional rate if shorter in duration. Phone calls regarding your child's progress in therapy between scheduled sessions are also available and billed at the pro-rata rate. Family/couple/child/parent confidentiality applies to individual sessions so confirm the appointment appropriateness with the psychologist prior to booking an individual session. Contact reception to be added to our waitlist.

Our current fee schedule can be found here

Consultation with other professionals/teachers/document review and reports/treatment updates (Non-Medicare/DVA review letters)

Phone calls, reports, treatment update letters and consultations with other professionals for assessment or clinical related communication will be billed at the pro-rata rate. Documents and emails are reviewed in session or billed at the sessional rate, and should be emailed to admin@aresolution.com.au and booked in advance.

Credit Card Authorisation Details Easy, Secure EWAY payments

Privacy Policy and Storage of Credit Card Details

We collect your name, credit card details and email address and store them securely in Eway for the purposes of streamlining our administration service to you, saving you and reception time at the end of your appointment.

Your details will not be passed onto any third parties. For your privacy, we only have access to the last 4 digits of your card after it is entered into the system.

If you are making payments for another party attending our service, providing your credit card details provides consent to make payment for up to 6 sessions of therapy, after which we will seek approval for another 6 sessions. You can withdraw your consent at any time by contacting admin@aresolution.com.au. Session information about the person attending therapy is kept in line with our confidentiality policy.

Payments

Invoices and direct debit payments are processed between 8 am and 9 am on the day of your booked session unless a third party payment agreement is in place. To make this run smoothly please ensure that funds are available the day prior.

Clients are responsible for ensuring they obtain valid referrals for the service and are responsible for the payment of session fees if they have not had sessions approved or obtained the relevant GP referral for NDIS, EAP, DVA, Work Cover or other third party payment providers.

Australian Defence Force Personnel

Please note that if your booking with us was made by an ADF medical officer or other personnel, a valid referral will be in place.

Unpaid Accounts

Payments are due on the day of service. We request timely payments of accounts to ensure smooth service delivery and medicare rebate processing. If you require a payment plan please let us know. If there is a dispute contact us so we can assist with your concerns. Unpaid accounts attract administration and reminder fees and may be subject to debt recovery fees and referred to an external debt recovery agency.

Late Notice Fee/Refunds/Dispute Resolution

Once you book an appointment it is yours, fees for your booked appointments are due on the day of service. We are able to offer video or phone sessions if you cannot make your appointment in person. On the day of the appointment, a late notice fee is charged unless you can provide a medical certificate for non-attendance at your session.

Dispute Resolution

Please provide a valid medical certificate if you wish to dispute your late notice policy fee or contact your psychologist directly. If you have any concerns about the quality of therapy please discuss this with your psychologist or the practice manager on 08 6555 7786 or email admin@aresolution.com.au.

Debit/Credit Card Details

Consent

Is there anything else you need us to know?This information will appear on your permanent appointment notes.

I have read and understood the credit card authorisation and service conditions in this document *

I will commit to attending in person or by phone/video and understand that I will be charged for late cancellations/reschedules/no shows and Medicare/Work Cover/DVA do not cover these fees *

Client signature *

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Date

I have read and understood the credit card authorisation and service conditions in this document *

I will commit to attending in person or by phone/video and understand that I will be charged for late cancellations/reschedules/no shows and Medicare/Work Cover/DVA do not cover these fees *

Family/Parent/Friend Signature *

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Family/Parent Friend Date

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