PERSONAL DETAILS

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    Other please specify:

    PARENT/GUARDIAN/CARER/PAYEE

    EMERGENCY CONTACT

    GP DETAILS



    MEDICARE DETAILS

    To receive a Medicare rebate we must receive both a Referral and a Better Access to Mental Health Care Plan from a general practitioner, paediatrician or psychiatrist prior or at the time of the appointment.


    Other type please specify:

    SERVICES AND CONSENT POLICY

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

    Fees

    All fees are to be paid at the time of consultation (Cheque / EFTPOS / Credit Card Available) unless you are provided a special exemption by your psychologist. Fee structures are variable dependent on the psychologist you see. Therefore, the out of pocket expense on Medicare rebated sessions (acquired through a Mental Health Care Plan from your GP) varies between $35 and $85 with full fee sessions costing between $150 and $200. Your psychologist will further discuss this with you during your first appointment.

    If funding is rejected for psychology services from any alternative referral sources clients will be responsible for full payments of any unpaid accounts.

    Information and Confidentiality

    Your psychologist will need to collect and record personal information from you that is relevant to your current situation. This information is a necessary part of the psychological assessment and treatment.

    All personal information gathered by your psychologist is treated as confidential and secure. Apart from communicating with your referring GP or Medical Specialist, we will not disclose any information about you to anybody or any organisation without your permission unless:

    1. Mandated by a court of law.
    2. We identify a threat to the safety of yourself, or someone else. In such an event, reasonable effort will be made to discuss this with you prior to any disclosure.
    3. Or you are a Primary Mental Healthcare (PHN) client as the funding is dependent on measurement outcome reports being reported to the PHN and GP.

    For service quality, and practice supervision purposes, clinical sessions may be recorded via audio and/or video means. Any recording is treated as strictly confidential.

    Where appropriate the service may be provided by telephone or videoconferencing. You are responsible for the costs associated with setting up the technology needed so you can access telehealth services. Emerge Psychological services will be responsible for the cost of the call to you and the cost associated with the platform used to conduct telehealth services. To access telehealth consultations you will need access to a quiet, private space; and the appropriate device, i.e. smartphone, laptop, iPad, computer, with a camera, microphone and speakers; and a reliable broadband internet connection.

    The privacy of any form of communication via the internet is potentially vulnerable and limited by the security of the technology used. To support the security of your personal information this practice uses Coviu which is compliant with the Australian standards for online security and encryption.

    Limitations of telehealth

    A telehealth consultation may be subject to limitations such as an unstable network connection which may affect the quality of the psychology session. In addition, there may be some services for which telehealth is not appropriate or effective. Your psychologist will consider and discuss with you the appropriateness of ongoing telehealth sessions.

    Research

    Assessment and treatment 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.

    Feedback and Complaints

    Your feedback, including complaints are welcome. If you decide to make a complaint, you can use any format available to you. You may contact us in person, via email address and our website. Any of these ways can be used to give feedback or make a complaint. We can provide you with a complaint form that may help you describe your complaint in a way that will speed up resolution.

    We attempt to address complains immediately, however promise to review all complaints within 2 working days. If complaints cannot be resolved within 2 working days, they are escalated to our business directors for their attention. Because we are psychologists, you are always able to make a complaint direct to the Australian Health Regulation Agency.

    Cancellation Policy

    Last minute cancellations or 'no-shows' mean that other clients miss out. A cancellation policy has been established to limit this from occuring. Please call us on 5221-1169 the day prior to your scheduled appointment to notify us of any changes or cancellations. If prior notification is not given, you may be charged a late cancellation fee of at least $50.

    Declaration

    I have read, understood, and agree with the Emerge Clinical Psychological Services, Services and Consent Policy. I agree to the above conditions for Face to Face or Telehealth Psychological services to be provided by Emerge Psychology.

    OTHER MENTAL HEALTH PRACTITIONERS/SERVICES

    Yes, involved with othersNo

    PRIVACY POLICY AND INFORMED CONSENT

    All personal information gathered by the psychologist during the provision of the psychological service will remain confidential. No information will be released without a signed consent form. Exceptions to this are;

    • If we are required by law to disclose information.
    • When there is a risk of serious danger to you or to another person. The clinician is ethically bound to take the necessary steps to prevent such danger.
    • If a referral is used from a paediatrician, psychiatrist or GP with a Mental Health Treatment Plan, a letter is required with a brief summary to the referring Dr after completion of each block of 6 then 4 sessions or earlier if required.
    • Your consent has been obtained to provide a written report or letter to another professional or agency or discuss the material with another person. E.g. parent, teacher and /or healthcare providers.
    • In the case of insurance or compensation claims, it may be necessary to disclose information and/or collect information that affects the client’s treatment.

    CONDITIONS OF SERVICE

    Additional cost not claimable through Medicare: Reports, letters, forms and consultations with other professionals. Costs are depended on individual requirements.

    Medicare Rebate: Medicare rebates are available with referrals from Paediatricians, Psychiatrists or from a General Practitioner with a GP Better Access to Mental Health Care Plan. Please ensure your referral is eligible for a rebate.

    Private Insurance: Private Health Insurance with ancillary cover rebates vary between funds and also the psychological service. Please make your own enquires with your private health fund prior to appointments. Introspect Psychology is unable to process private health rebates, it is the client’s responsibility to claim their rebate.

    FaHSCIA Funded Clients: Please note if clients have insufficient funding available to pay for services their carers/Parents are responsible for the account being paid. FAHSCIA will not pay for cancellation fees or for appointments not attended.

    NDIS Funded Clients: Please note if clients have insufficient funding available to pay for services through NDIS, the client or their carers/Parents are responsible for the account being paid.

    Workers Compensation Clients: Approval has been sought for a specified amount of sessions through your insurance company, if further sessions are required this will be a cost to the client.

    Cancellation Fees: Please contact as early as possible to reschedule or cancel appointments, otherwise

    • Cancellation under 24hrs prior to appointment: $100 per session
    • Non Attendance: Full fee charged for clients who fail to attend an appointment.

    Overdue/unpaid accounts: Introspect Psychology will follow up on any outstanding accounts after 14 days unpaid. If you fail to settle your account, Introspect Psychology will refer any unpaid accounts to a debt collection and management service after 90+ days.

    If l have any questions regarding this consent form or about services offered at Introspect Psychology, I may discuss them with my Psychologist. I have read and understood the above.

    Signature/Date

    OR Where a signature is not possible Psychologist’s confirmation of Verbal consent: I Have discussed the information in the consent form with the client and received verbal consent to proceed with Telehealth services.


    Other please specify:

    Workover/TAC Details (if applicable)

    NDIS Details (if applicable)

    UNDER 16 PARENT/GUARDIAN INTAKE DETAILS

    Parent/Guardian details to be entered below.

    I agree to the Introspect Psychology Terms of Service outlined above
    ClientGuardianCarer