New Client Intake and Consent Form – The Talk Shop

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Psychological Service Personal Information

As part of providing a psychological service to you, we 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 may view and/or have a copy of the material recorded in your file upon request, subject to the exceptions in National Privacy Principle 6.

Confidentiality

All personal information gathered by the psychologist during the provision of the psychological service will remain confidential and secure within the organisation except when:

It is subpoenaed by a court, or
Failure to disclose the information would place you or another person at risk; or
Your prior approval has been obtained to:
- provide a written report to another previously uninvolved professional or agency.e.g. a GP or a lawyer; or
- discuss the material with another person. e.g. a parent or employer

Please note that as part of the Better Access Program, Medicare insists that psychologists write a number of reports to your GP during the course of treatment to ensure that you continue to receive a rebate and the GP remains involved in the treatment.

While email is regularly used to schedule appointments, we do not recommend you send confidential information to your psychologist via email, as email is not secure and your privacy cannot be guaranteed.

Service provision via telehealth

Where suitable, therapy may be provided to you by video call or phone call (collectively referred to as “telehealth”).

You are responsible for your own technology costs associated with setting yourself up to access telehealth services.

The Talk Shop will be responsible for the cost of the call to you and the cost associated with the platform used to conduct telehealth services.

To access telehealth sessions you will need access to a quiet, private space; an appropriate device (e.g. smartphone, computer, webcam); and a reliable broadband internet connection. Detailed information is available on our website.

The privacy of any form of communication via the internet is potentially vulnerable and limited by the security of the technology used. To support the security of your personal information, for video calls we use Jitsi Meet, hosted on our own secure servers, with end-to-end encryption.

A telehealth session may be subject to technical limitations such as an unstable network connection which may affect the quality of the psychology session.

Telehealth might not be suitable for your treatment. Your psychologist will consider and discuss with you the appropriateness of ongoing telehealth sessions.

Cancellation and Fee Policy

If you need to cancel or postpone the appointment, please give us at least 24 hours’ notice, otherwise, you may be charged the cost of the session.

When we bill a funder directly, you assign us the right to receive payment directly from that funder. If the funder refuses to pay, you are responsible for paying for the session and any fees for collecting the payment. Funders include Medicare, NDIS, TAC, VOCAT, WorkSafe, Comcare, DVA, and similar organisations.

Limitations of service

You acknowledge that we are not an emergency service, are not always available at short notice or outside our regular practice hours, and we may not be able to respond to telephone calls or emails requesting urgent assistance. Ask your psychologist if you wish to be provided with the details of other services who can provide these services.

Prefix*

Prefix

First Name*

First

Middle Name

Middle

Last Name*

Last

Preferred Name

First

Date of Birth*

YYYY dash MM dash DD

Gender*

Female

Male

Other

Pronoun (Optional)

e/em/eir/eirs/emself

he/him/his/his/himself

she/her/her/hers/herself

they/them/their/theirs/theirself

xe/xem/xyr/xyrs/xemself

ze/hir/hir/hirs/hirself

Other

Medicare Card Number

Number next to your name

Valid To Date

Residential Address (must NOT be PO Box, etc)*

This is your Residential Address as registered with Medicare Australia. If this does not match the address held with Medicare, your Medicare claim will fail and you will not receive Medicate Rebates. Postal addresses such as a PO Box, etc, must not be entered here.

Street Address Address Line 2 Suburb State Postcode Country

Email*

Enter Email Confirm Email

Mobile Phone*

Name of the person and organisation who referred you or recommended this service:

If the client is a minor, please provide details of the parent/guardian filling in this form

Medical Practitioner

Name:

Phone

Date of last contact

YYYY dash MM dash DD

Previous Counsellor/therapist (if any)

Name

Phone

Date of last contact

YYYY dash MM dash DD

Is there anything we should or need to know about yourself or your situation that might affect your safety or the safety of our staff?*

Do you have any unresolved legal matters?*

Briefly describe the reason for your visit*

When is a good time to call to book an appointment*

Morning (before 11 am)

Lunchtime (11 am to 2 pm)

Afternoon (2 pm to 5 pm)

Evening (after 5 pm)

Please select all locations you are willing to travel to*

Brandon Park / Wheelers Hill

Melbourne CBD (Little Collins Street)

Mooroolbark

Reservoir

Would you be willing to see a practitioner via Telehealth (Video Call or Telephone Call)?*

Yes

I have read and understood the above Consent Form. I agree to these conditions for the psychological service provided by The Talk Shop for myself, and /or the minor(s) under my care.

Signature*

On clicking Submit, we will send you a confirmation email, with information on getting the necessary paperwork to us.

Please Note: If, after reading this page you are at all unsure of what is written, please discuss it with the psychologist