Client Information Form

PERSONAL DETAILS

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GP DETAILS

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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.

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NDIS AGENCY MANAGED CLIENTS

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Other mental health practitioners/services

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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. PPS 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: PPS will follow up on any outstanding accounts after 14 days unpaid. If you fail to settle your account, PPS 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 Perth Psychological Services, I may discuss them with my Psychologist. I have read and understood the above.

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Contact Us

Locations

  • Victoria Park
    7/76 Canning Highway
    Victoria Park WA 6100

  • Subiaco
    Homebase Business Centre
    Ground Floor 55 Salvado Rd
    Subiaco WA 6008

  • Mandurah
    Unit 1/33 Davey Street
    Mandurah WA 6210

Services

  • Autism Spectrum Disorder
  • Neurodevelopment Assessments
  • Depression
  • Anxiety and Panic
  • Self Esteem
  • Relationship Issues
  • Family Concerns
  • Parenting
  • Adolescent Behaviour
  • Childhood Trauma

  • Post Traumatic Stress

Services

  • IVF & Reproductive Issues
  • Work-Related Stress and Career Issues
  • Substance Misuse and other Dependencies
  • Postnatal Depression
  • Gender Identity
  • Chronic and Terminal Illness
  • Grief and Loss
  • Bereavement
  • Health and Well-Being

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