Client Intake Form

First Name: Surname:

Address:

Suburb: Postcode:

1. Do you identify as any of the following (please circle):

Aboriginal: YES/NO

Torres Strait Islander: YES/NO

2. Do you speak another language? ________________________________

3. Do you require an interpreter? YES/NO_______________________

4. Do you have a current mental health care plan? YES/NO

5. Medicare Card Number:______________________________

Your reference number______

IF YOU DO NOT HAVE A MENTAL HEALTH CARE PLAN YOU WILL BE

BILLED THE REBATE FEE OF $84.80 UNLESS ALTERNATIVE

ARRANGEMENTS HAVE BEEN MADE FOR FUNDING YOUR SESSION.

The following is optional and you don’t have to fill it out. The purpose of asking these question’s, is to help save some time at our first appointment. If you don’t want to answer these questions, that is absolutely fine.

In a few words, tell us why you want to see one of our counsellors:

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Have you ever seen a counsellor before: YES/NO

If so, is there anything about your previous counselling you think may be helpful for us to

know about:

___________________________________________________________________________

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___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

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Please tell us about any medication you are on:

___________________________________________________________________________

___________________________________________________________________________

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Are you concerned about your own or someone else’s safety?

___________________________________________________________________________

___________________________________________________________________________

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Consent Form

Psychological Service

As part of providing a counselling based psychological service to you, the psychologist will need to

collect and record personal information from you that is relevant to your current situation. This

information will be a necessary part of the psychological assessment and treatment that is

conducted. You do not have to give all your personal information, but if you don’t, this may mean

we may not be able to provide you with a psychological service.

Purpose of collecting and holding information

The information is gathered as part of the assessment, diagnosis and treatment of a client’s

condition, and is seen only by the psychologist. The information is retained in order to document

what happens during sessions, and enables the psychologist to provide a relevant and informed

psychological service.

Access to Your Information

At any stage you as a client are entitled to access to the information about you kept on file, unless

the relevant legislation provides otherwise. The psychologist may discuss with you appropriate

forms of access.

Confidentiality and Exchanging Information

All personal information gathered by the psychologist during the provision of the psychological

service will remain confidential and secure except where:

1. It is subpoenaed by a court, or

2. Failure to disclose the information would place you or another person at serious and

imminent risk; or

3. Your prior approval has been obtained to

a) provide a written report to another professional or agency. eg. a GP or a lawyer; or

b) discuss the material with another person, eg. a parent or employer; or if disclosure is

otherwise required or authorised by law.

Fees

The cost of a one-hour consultation (usually around 50 minutes) is free as it is bulk billed providing

you have a current and valid mental health care plan from your GP. If you do not have a current or

valid mental health care plan you will be charged the current Medicare prescribed fee.

Cancellation Policy

If, for some reason you need to cancel or postpone the appointment, please notify us as soon as

possible. We prefer at least 24 hours’ notice for cancellations. Cancellations with less than 24-hours

notice and ‘no shows’ may incur a fee of up to $84.8. We understand there are exceptional

circumstances that may lead to a ‘no show’ or cancellation and this fee may be waived in certain

circumstances at the discretion of the psychologist.

I, ……………………………………………….., have read and understood the above Consent Form. I

acknowledge that I have been given a copy of the privacy management policy. I agree to these

conditions for the psychological service provided by………………………………….

Signature ……………………………………………… Date ……………………..

Please Note: If, after reading this page you are at all unsure of what is written, please

discuss it with the psychologist.

Psychologist Signature……………………………………..

Policy of Management of Personal Information

This document describes the policy of Open Minds Psychological Services for the management of the

practice’s clients’ information. The psychological service provided is bound by the legal

requirements of the National Privacy Principles from the Privacy Amendment (Private Sector) Act

2000.

Client Information

Client files are held in a secure filing cabinet which is accessible only to authorised employees. The

information on each file includes personal information such as name, address, contact phone

numbers, and other information which is relevant to the psychological service being provided. Some

of your information will be stored electronically for appointment and bulk billing purposes. This

information is accessed via a secure, password protected network. Some information about your

referral will be used in business reports but all identifying information will be omitted. This will help

Open Minds work collaboratively with other organisations and services to deliver quality services to

the community.

Purpose of holding information

The information is gathered as part of the assessment, diagnosis and treatment of the client’s

condition, is seen only by the psychologist. The information is retained in order to document what

happens during sessions, and enables the psychologist to provide a relevant and informed

psychological service.

Requests for access to client information

At any stage clients may request to see the information about them kept on file. The psychologist

may discuss the contents with them and/ or give them a copy. All requests by clients for access to

information held about them should be lodged with Melissa Duckmanton by contacting her on 0423

620 516. These requests will be responded to within 7 business days and an appointment will be

made if necessary for clarification purposes.

Concerns

If you have a concern about the management of your personal information, please inform Melissa

Duckmanton on 0438 500 251. Upon request you can obtain a copy of the National Privacy

Principles, which describe your rights and how your information should be handled. Ultimately, if

you wish to lodge a formal complaint about the use of, or access to, your personal information, you

may do so with the Office of the Federal Privacy Commissioner on 1300 363 992, or GPO Box 5218,

Sydney, NSW 1042.

Cancellation and No-show Policy

We understand that sometimes things come up or happen and it means you need to change or cancel your appointment with us. We ask that you give us at least 24 hours’ notice if you need to change or cancel your appointment. We have a lot of people who use our service that phone to make urgent appointments and we have people waiting on a wait list to see one of our Psychologists. If you notify us at least 24 hours before, it gives us the chance to offer that spot to someone else who may benefit from that support. If you don’t show up for your appointment without notifying us, it is a waste of valuable resources and time. Given we are a bulk billed service; it means we also don’t get paid. To help us to continue to be a free service we ask that you take responsibility for your appointments and notify us if you are unable to attend. Unless there are exceptional circumstances, your Psychologist may request you pay up to $84.8 if you fail to give at least 24-hours’ notice to cancel your appointment, or if you do not show up to your appointment. This fee will be payable before any future appointments are made. Your Psychologist will notify you if this fee is payable and of the exact amount. You can make payments to the following bank account. Please ensure you put your full name in the reference so we know where the deposit has come from. Open Minds Psychological Services Bank of Melbourne BSB: 193-879 ACCOUNT: 486355425