Client Registration Form - Child

CLIENT DETAILS

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender *

Preferred Pronouns

English is a Second Language

YesNo

ATSI

AboriginalTorres Strait IslanderNone of the Above

Contact Details *

Street address *

City *

State *

Postcode *

Who else lives at child's home? *

Who are your child's significant others NOT living at this home?

Accessibility Requirements

Who referred you to this clinic? How did you hear about us? *

What is your main reason for requesting a visit? *

PARENT CONTACT DETAILS

First Name *

Last Name *

Address, if different to child

Occupation *

Home Phone

Mobile Phone *

Work Phone

Email *

PARENT 2 CONTACT DETAILS

First Name

Last Name

Address (if different to child)

Street address

City

State

Postcode

Occupation

Home Phone (if different)

Mobile Phone

Work Phone

Email

NEXT OF KIN CONTACT DETAILS

Is the next of Kin same as details already given? (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

FAMILY HISTORY

Biological MotherIf different to information supplied above

Biological FatherIf different to information supplied above

Who has legal guardianship of your child? Please supply copy of any Court Orders in place if applicable for your family

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

Did the child's mother have any problems during pregnancy or delivery? If yes, please describe

Please 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)

Please provide Primary Cardholder Name, DOB and Card number *

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

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

Fund Manager Name *

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

Yes

WORKERS COMPENSATION or THIRD PARTY INSURERS

Are you attending under Work Cover or CTP

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

EDUCATION HISTORY

Current year at School *

Name of School *

What does your child's teacher say about him/her? *

Is your child participating in any special education programs/learning support at school? *

Yes No

If yes, please describe

Has your child ever had to repeat a grade? *

If yes, which one/s?

Other Schools attended (including Pre-School)

Please detail

Teacher Contact Details

BEHAVIOURAL HISTORY

What behaviours are occurring with greater frequency or intensity then you would like?

What would you like to see happening more often?

What are your child's strengths?

Treatment Goals:

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

What are some of the things that are currently stressful to your child and his/her family?

Relevant Reports/Documents

Browse

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

Other ConcernsDo you have any other concerns about your child or your family that you have not mentioned yet?

FEES

Rate as at 1 July 2023

Service	Cost	Medicare Rebate
Clinical Psychology Therapy Session	$240	$136.35*
Senior Registered Psychology Therapy Session	$210	$92.90*
Registered Psychology Therapy Session	$200	$92.90*
Provisional Psychology Therapy Session	$110	N/A
Assessment and Report**	$650-$2100 (inc GST)	N/A
Support Letter	$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 2 - 5 hours of assessment as well as up to three 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 an under NDIS or Work Cover *

Yes

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 or email info@jgpsychology.com.au.

If less than 24 hours notice is given, a cancellation fee will be applied and is to be paid prior to your next appointment being booked.

I am aware that a cancellation fee applies if I do not give more than 24 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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