Client Registration Form - Adult

CLIENT DETAILS

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender *

Preferred Pronouns

Prefixeg: Ms, Mx, Mrs, Mr, Dr

English is a Second Language

YesNo

ATSI

AboriginalTorres Strait IslanderNone of the Above

Accessibility Requirements

How did you hear about us / who referred you?

What is your main concern / reason for visit? *

CLIENT CONTACT DETAILS

Home Phone

Mobile Phone *

Work Phone

Email *

Contact Details *

Street address *

City *

State *

Postcode *

EMERGENCY CONTACT DETAILS

Name *

Relationship

Contact *

Street address *

City *

State *

Postcode *

Home Phone

Mobile Phone *

Email

Work Phone

NEXT OF KIN CONTACT DETAILS

Is the next of Kin same as your emergency (if yes, you do not need to fill this section) *

YesNo

Next of Kin - Name

Next of kin - Email

Next of kin Home Phone

Next of kin - Mobile Phone

Best way to contact your next of Kin

Home PhMobile PhWork Ph

MEDICAL HISTORY

Referring Doctor’s Name

Address

Family Doctor/ Regular General Practitioner Name (if different to referring doctor)

Address

Do you have a Mental Health Care Plan *

YesNo

Please attach if you have a copy

Browse

Please list any current medications

Please list any current medical problems and/or physical impairments

MEDICARE

Medicare Card No. *

Expiry

Do you use a different name in your medicare card?

YesNo

If you use Alias please write the Alias name & surname

Medicare First Name

Medicare Surname

Medicare Address (if different to your residential address)

If you are under 21 and remain on a Parent Medicare Card, please provide Primary Cardholder Name, DOB and Card number

DVA

Do you hold a Veteran Health Care Card *

YesNo

DVA File Number

DVA Card Type

Accepted Disabilities

Condition to be Treated

Period Enlisted with ADF

Details of Active Service (if any)

PRIVATE HEALTH INSURANCE

Do you have private Medical insurance *

YesNo

Provider

Membership No.

Expiry

NDIS

Are you an NDIS Participant *

YesNo

NDIS Number *

NDIS Plan Expiry Date *

My funds are managed by *

Name of Fund Manager *

I am aware if my NDIS funds are exhausted, I am responsible for payment of my sessions *

Yes

Local Area Co-ordinator Name

Contact Number/Email

Support Co-Ordinator *

Contact Number / Email *

Please attach a Copy of your Plan

Browse

I am aware that a Service Agreement will be prepared after my first session

Yes

WORKERS COMPENSATION

Are you attending under Work Cover

YesNo

Insurer Name

Claim Number

Case Manager Name

Insurer Contact Number/Email

I am aware if the Insurer declines liability, my account is my responsibility

Yes

FEES

Rate as at 1 July 2024

Annual Fee Increase applies at 1 July 2025

Service	Psychologist	Cost	Medicare Rebate
Clinical Psychologist Therapy Session	Jon Grainger	$240	$141.85*
Senior Registered Psychologist Therapy Session	Anita Leckie	$220	$96.65*
Provisional Psychologist Therapy Session	Jessica Abel Lisa Passmore Deen Rawling	$200	Fee reduced to $120 as no Medicare Rebate
Assessment and Report**	Jacqui Ross All Psychologists	$650 - $2,496 (inc GST)	N/A
Pre-Assessment Interview	All Psychologists	$240	N/A
Support Letter	All Psychologists	$240 + GST	N/A

* Rebate is provided under the Better Access to Mental Health system, which requires a referral from your GP, who will also submit a Care Plan to Medicare authorising the initial course of six sessions.

** Assessments for specific conditions (eg. Autism or Major Depressive Disorder) or for particular purposes (eg. to prepare for surgery or as to be considered for employment in the armed services) typically require 3- 5 hours of assessment as well as up to five hours to prepare the report and gather additional information. As such costs of individual assessments may vary, a quote will be provided to you before you commence the assessment.

I am aware there is a fee for service that is payable at the end of the session unless I am under DVA, NDIS (NDIA or Plan Managed) or SIRA Approval *

Yes

BEHAVIOURAL BACKGROUND

What Behaviours are occurring with greater frequency or intensity than you would like? *

What would you like to see happening more often? *

What are your strengths? *

Treatment Goals: *

Please describe any past counselling that either you or other family members have had

What are some of the things that are currently stressful to you and / or your family?

Provide any relevant work history that you think is important to mention

Relevant Reports and Documents

Browse

Please attach any other relevant reports or documentation that you feel would be helpful for your clinician to review.

Other Concerns

AVAILABILITY

Availability Options

9AM to 12:00PM12:00PM to 3:00PM3:00PM to 5:00PM5:00PM and later

Days of the Week Available

Are you available for Appointments at Short Notice?

YesNo

CANCELLATION POLICY

One week before your booked appointment, an automatic email will be sent, allowing you time to plan ahead and make any arrangements necessary so as you can attend. The day before, an automatic SMS reminder is sent, which asks you to respond CONFIRM or contact to RESCHEDULE.

If you are unable to make your next appointment please inform us via text on 0418 849 417, calling Reception on 0249348685 or email info@jgpsychology.com.au.

We have a number of people on our waitlist, and appreciate notice if you are unable to attend so that the opportunity can be given to another client in need.

If less than 48 hours notice is given, a cancellation fee will be applied and is to be paid prior to your next appointment being booked unless we have been able to fill your spot.

I am aware that a cancellation fee applies if I do not give more than 48 hours notice or do not attend *

Yes

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature

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