Personal Details

First Name

Last Name

Preferred Name

Title (Required)

Date Of Birth (Required, please enter dd/mm/yyyy)

Age (Required, please enter years as number e.g. 34)

Email Address (Required)

Postal Address (Required)

Suburb (Required)

State

Postcode (Required)

Mobile Phone (Required)

OK to leave message (Required)?
YesNo

Home Phone

OK to leave message?
YesNo

Work Phone

OK to leave message?
YesNo

Medicare Card Number

Number Before Name

Expiry Month

Expiry Year

Emergency Contact Details

Name (Required)

Relationship (Required)

Telephone (Required)

How Did You Hear About Us?

Select One (Required)

GP ReferralFriend/colleagueOtherInternet SearchEAP ReferralWorkYellow PagesSchool

Doctor's Name (Required)

Name (Required)

Please Specify (Required)

Release/Obtain Information

I GIVE PERMISSION FOR LIFE MATTERS PSYCHOLOGISTS TO RELEASE/OBTAIN INFORMATION WITH REGARDS TO MY ASSESSMENT/TREATMENT TO/FROM

General Practitioner Name

General Practitioner Address

General Practitioner Phone

Release?
YesNo

Obtain?
YesNo

 

Insurance Co. Name

Insurance Co. Address

Insurance Co. Phone

Release?
YesNo

Obtain?
YesNo

 

Solicitor Name

Solicitor Address

Solicitor Phone

Release?
YesNo

Obtain?
YesNo

 

Other Name

Other Address

Other Phone

Release?
YesNo

Obtain?
YesNo

 

Terms & Conditions

Privacy Policy for Management of Personal Information and Consent Form

This document describes the privacy policy of Life Matters Psychologist for the management of clients’ personal information. The psychological service provided is bound by the legal requirements of the Australian Privacy Principles set out in the Privacy Act 1988 (Cth).

Client information

Client files are stored in an electronic document management system which is accessible only to authorised employees. The information on each file includes personal information such as name, address, contact phone numbers, medical history, and other personal information collected as part of providing the psychological service.

How clients' personal information is collected

A client's personal information is collected in a number of ways during psychological consultation with Life Matters Psychologists including when the client provides information directly to Life Matters Psychologists using hardcopy forms, correspondence via email, when the client interacts directly with Life Matters Psychologists employees such as the receptionist, and when other health practitioners provide personal information Life Matters Psychologists, via referrals, correspondence and medical reports.

Consequence of not providing personal information

If the client does not wish for their personal information to be collected in a way anticipated by this Privacy Policy, Life Matters Psychologists may not be in a position to provide the psychological service to the client. Clients may request to be anonymous or to use a pseudonym, unless it is impracticable for Life Matters Psychologists to deal with the client or if Life Matters Psychologists is required or authorised by law to deal with identified individuals. In most cases it will not be possible for the client to be anonymous or to use a pseudonym, however if the psychologist agrees to the client being anonymous or using a pseudonym, the client must pay consultation fees at the time of the appointment.

Purpose of holding personal information

A client’s personal information is gathered and used for the purpose of providing psychological services, which includes assessing, diagnosing and treating a client’s presenting issue. The personal information is retained in order to document what happens during sessions, and enables the psychologist to provide a relevant and informed psychological service.

Disclosure of personal information

Clients’ personal information will remain confidential except when:

  • 1. It is subpoenaed by a court; or
  • 2. Failure to disclose the information would in the reasonable belief of the Life Matters Psychologists place a client or another person at serious risk to life, health or safety; or
  • 3. The client’s prior approval has been obtained to:
  • a) provide a written report to another professional or agency, e.g., a GP or a lawyer; or
  • b) discuss the material with another person, e.g. a parent, employer or health provider; or
  • c) disclose the information in another way; or
  • 4. you would reasonably expect your personal information to be disclosed to another professional or agency (e.g. your GP) and disclosure of your personal information to that third party is for a purpose which is directly related to the primary purpose for which your personal information was collected; or
  • 5.disclosure is otherwise required or authorised by law.

If you have been referred by a GP under a Mental Health Care Plan (MHCP) we are obligated to provide a letter to your GP after the initial appointment, the 6th and 12th appointments. There is no charge for these letters.

A client's personal information is not disclosed to overseas recipients, unless the client consents or such disclosure is otherwise required by law. Clients' personal information will not be used, sold, rented or disclosed for any other purpose.

Requests for access and correction to client information

At any stage clients may request to see and correct the personal information about them kept on file. The psychologist may discuss the contents with them and/or give them a copy, subject to the exceptions in the Privacy Act 1988 (Cth). If satisfied that personal information is inaccurate, out of date or incomplete, reasonable steps will be taken in the circumstances to ensure that this information is corrected. All requests by clients for access to or correction of personal information held about them should be lodged with Life Matters Psychologists. These requests will be responded to in writing within 30 days and an appointment will be made if necessary for clarification purposes.

Concerns

If clients have a concern about the management of their personal information, they may inform Matthew Stanton, Partner and Clinical Psychologist, Life Matters Psychologists, 02 4965 3530. Upon request they can obtain a copy of the Australian Privacy Principles, which describe their rights and how their personal information should be handled. Ultimately, if clients wish to lodge a formal complaint about the use of, disclosure of, or access to, their personal information, they may do so with the Office of the Australian Information Commissioner by phone on 1300 363 992, online at http://www.oaic.gov.au/privacy/making-a-privacy-complaint or by post to:

Office of the Australian Information Commissioner, GPO Box 5218, Sydney, NSW 2001.

Fees

Payment is required at the time of treatment. The fee to see a clinical psychologist is $210 for a standard consultation of 45-60 minutes. The fee to see a registered psychologist is $195-$205 for a standard consultation of 45-60 minutes. All requested letters and reports (excluding progress letters to your GP if you are under a Mental Health Care Plan) will be charged at a percentage of hourly rates and a quote can be provided on request. Fees are reviewed annually each year. We are registered with most private health funds so you may be entitled to a rebate through your fund. If you have a Doctor’s MHCP/ referral you will receive a rebate back through Medicare. Simply take the receipt you are given at your session to a Medicare office to make a claim. If you are registered with Medicare online services, we can lodge your claim with Medicare who will process your rebate into your nominated account the following business day. Enquiries for Medicare rebate issues can be made by calling 132011. Payment in full by cash, EFTPOS, Visa or MasterCard will be collected prior to your consultation. No accounts will be sent.

FEES – EAP/ WORK COVER

EAP - An account will be sent to your employer for payment. Please note that you will not be identified on any accounts.

WORK COVER – Payment for treatment is provided by your employers Workers Compensation Insurance Company based on your claim being accepted. For seeing a psychologist an initial consultation is $220.10 it will cost $183.60 for a standard consultation if you have an accepted claim. An account will be sent to your employers insurance company for payment. However if your claim is at any point denied by the insurer fees will then become payable by yourself the client.

Cancellation Policy

If, for some reason you need to cancel or postpone the appointment, please give us at least 24 hours notice. Please note that for cancellations, ‘no shows’, or changes to appointments past 12pm the day prior to the appointment which leads to lost sessional income you will be charged the full fee. These fees must be paid before another booking can be taken.

Cancellation Policy EAP

If, for some reason you need to cancel or postpone the appointment, please give us at least 24 hours notice. Please note that for cancellations, ‘no shows’, or changes to appointments past 12pm the day prior to the appointment which leads to lost sessional income may impact on your access to EAP sessions. If your employer’s EAP has a sessional limit (how many sessions available to you) this may count as a session utilised.

Cancellation Policy WORK COVER

If, for some reason you need to cancel or postpone the appointment, please give us at least 24 hours notice. Please note that for cancellations, ‘no shows’, or changes to appointments with less than 24 hours notice, which leads to lost sessional income, will be charged at the full fee to yourself the client. These fees will not be paid for by the insurer. These fees must be paid by yourself before another booking can be taken. In the case that you fail to attend an appointment or give sufficient notice then a cancellation charge is made to your nominated card and a receipt will be sent to you via email or mail. If you do not have a credit card we will send you a bill for the missed appointment.

I HAVE READ AND AGREE TO THE TERMS AND CONDITIONS FOR THE PSYCHOLOGICAL SERVICE PROVIDED BY LIFE MATTERS PSYCHOLOGISTS

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