Please complete and submit this form prior to attending your appointment. All information will be stored confidentially.

This form must be completed and reviewed before an appointment is confirmed. The Psychologist reserves the right to decide whether to proceed with a booking.

Name

First Name

Last Name

Preferred pronouns

Mobile Phone

(###)

###

####

Date of Birth

YYYY

Address

Referring Doctor & Medical Centre (if applicable)

Name & contact number of nominated contact person

My nominated contact person knows that I am attending this appointment

Option 1

Medicare Number

Medicare Expiry Date

Medicare Reference Number

If you are eligible for a MHCP Medicare rebate, and you would like us to process this for you, please provide preferred bank account details if Medicare does not have these already. Please note: Medicare rebates only apply to individuals with a valid Mental Health Care Plan. We can only lodge your Medicare claim but do not control the Medicare rebate payment process into your bank account. If preferred, you can claim your Medicare rebate yourself after your appointment, by submitting your paid receipt directly to Medicare for review

Account Name

BSB

Account Number

Fees

I understand the cost of a 50 minute face-to-face or telehealth psychological counselling appointment is $240 with a Medicare rebate of $98.95 if I obtain a MHCP from my GP.

Payment

I consent to Rachel Tyson Psychology charging the credit card I supply for the session fee owing OR

I agree to be invoiced and pay my invoice within 2 days.

Medicare

I consent to Rachel Tyson Psychology claiming my Medicare rebate on my behalf (if eligible).

I have provided my correct bank account details for the Medicare rebate deposit.

Cancellation

I understand that a cancellation within 24 hours of my appointment will incur a cancellation fee, unless it is the result of a proven health directive.

Record Keeping and Confidentiality

I understand as part of providing a psychological service, Rachel Tyson Psychology needs to collect and record personal information from me that is relevant to my situation, such as my name, contact information, medical history and other relevant information as part of providing psychological services to me. This collection of personal information will be a necessary part of the psychological assessment and treatment that is conducted. All information is treated as confidential and bound by the APS Psychologists Code of Conduct.

I understand that information gathered during the provision of the psychological service will remain confidential except when: 1. Subpoenaed by a court 2. Failure to disclose the information would place me or another person at serious risk to life, health or safety. 3. If my prior approval has been obtained to a) provide a written report to another professional agency eg a GP or a Lawyer or b) discuss the material with another person eg a parent or employer, health provider or third party funder or disclose the information in another way, or c) disclose to another professional or agency eg 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.

If any of this is unclear, please contact us before your appointment.