Personal Details

Full Name (Required)

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

Postal Address (Required)

Suburb (Required)

Postcode (Required)

Phone Number (Required)

OK to leave message (Required)?
YesNo

Medicare Card Number (Required)

Number Before Name (Required)

Expiry Month (Required)

Expiry Year (Required)

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)

Consent Information

Indicate who is consenting to collection, use and disclosure of personal health information.

Yes – Adult client is consentingYes – Child/adolescent client is consentingYes – Parent/guardian is consenting (on behalf of child/adolescent client)

I agree that information about my mental health and wellbeing may be collected, used and disclosed to the mental health provider(s) to whom I am referred, where this is required to assist in the management of my health care.

I am also aware that information (that will not identify me to any external parties) is being collected and used to assist in improving the PMHCS program, and I agree to this deidentified information being collected and shared.

I consent to the following modes of service delivery:

Face-to-face with psychologistPhone-based psychological serviceInternet video conferencing

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. For seeing a clinical psychologist, it will cost you $195 per 50 min session. For seeing a psychologist, it will cost you $185 per 50 min session. 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 provide a rebate directly to your account on the day of your appointment. Payment in full by cash, EFTPOS, Visa or MasterCard will be collected prior to your consultation. No accounts will be sent.

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.

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

Patient Digital Signature

Parent Digital Signature