MindWare Psychology
121 West Street Toowoomba Q 4350
Tel 07 46 464952
[email protected]www.mindwarepsychology.com.au
ABN 74609288664 ACN 609288664
Client Information Form
Title (please circle): Dr Mr Mrs Ms Master Miss Other
Last Name:________________________ First Name:______________________
Date of Birth:_______________________ Parent/guardian Name:____________________
Medicare #:________________________ Position:_______ Expiry:______________
Home Address:___________________________________________________________
__________________________________________________________________________________
Postal Address:_____________________________________________________________________
__________________________________________________________________________________
Contact Numbers: Home:_______________________ Mobile:_______________________
Work:_______________________ Email:____________________________________________
Next of Kin: (Please provide the contact details of the person you would like us to contact in an emergency.)
Name:______________________ Relationship to you:______________________
Phone Number: Home__________________ Mobile____________________
Are you a member of a private heath fund?_________ Name of Fund:____________________
During Business Hours, how would you most like us to contact you if necessary? (please circle)
Home Work Mobile Email SMS
*With regards to confidentiality, do you have any specific requests if we need to contact you for any
reason:___________________________________________________________________________
Referring Doctor:____________________________________ Date of referral:_______________
Is this your usual doctor? YES NO (if no please provide details of your regular GP)
GP Details:________________________________________________________________________
Are you seeing or have you seen any another other specialists? eg. Psychiatrist, Speech Therapist, OT
YES NO (if yes please provide contact details of these specialist below).
Name of Specialist:_______________________ Contact details:_______________________
Name of Specialist:_______________________ Contact details:_______________________
Do you have a current Mental Health Plan? YES NO
Are you being referred under any other program? (please list program)________________________
Are there any court orders in place? YES NO (if so please provide information)
How did you hear about this service? ___________________________________________________
MindWare Psychology
121 West Street Toowoomba Q 4350
Tel 07 46 464952
[email protected]www.mindwarepsychology.com.au
ABN 74609288664 ACN 609288664
CLIENT CONSENT FORM
Background and Services
MindWare Psychology is a psychology practice based in Toowoomba. We believe everyone
can change and reach their potential through a respectful, creative and ethical journey.
As part of providing a service to your MindWare practitioners will need to collect and record
personal information from you that is relevant to your situation. This information is a
necessary part of the services provided and guides the treatment. Please ensure you provide
honest and comprehensive information to help us meet treatment needs. You do not need to
give all of your personal information, but if you don’t, this may impact on our service
delivery. Our information is stored using secure electronic systems that adhere to Australian
Privacy Laws. If you have further questions please ask your treating practitioner.
Privacy
The information we gather is treated in a confidential manner and is only seen by those who
need to see the information to support you for your treatment. The information is retained in
order to document what happens during sessions, and enables the treating practitioner to
provide a relevant and informed psychological service. You are able to ask for your
information and ask to review what is on file unless there is relevant legislation that indicates
otherwise. Your treating practitioner will discuss the appropriate way to access your
information.
Confidentiality
Please be assured that all information provided in the process of consultation is strictly
confidential. Only the assigned practitioner can access your session notes and our
administration staff see limited information to support you with bookings. Other than the
special circumstances outlined below, no information may be released to others without the
written consent from you or your guardian.
These special circumstances include the following:
1. Where a court orders the release of client information for legal purposes
2. Failing to disclose the information would place you or another person ibn serious or
imminent risk.
3. Where the treating practitioners is seeking peer support from other practitioners in the
clinic to provide you with the best service
4. Your prior approval has been obtained to provide a written report other agency (eg: GP,
Lawyer) or discuss the material with another person eg: parent, employer, teacher.
5. If the disclosure is required by law.
Please note that if you have been referred by a medical professional on a Government funded
intervention (such as a Mental Health Plan) then it is usual practice to provide a written
reports. The reports provide limited information about your progress with the authorised
treatment.
Please note that you have the right to refuse this consent. However, in certain situations,
your refusal may mean that you will not be able to proceed with services at the clinic,
especially if they are funded through a collaborative government scheme that requires
reporting.
Fees
The cost of a 50 minute consultation varies depending on your treating practitioner. This cost
will be agreed and discussed before your appointment or during your first appointment with
your treating psychologist. The agreed scheduled fee is $130 or as negotiated with your
practitioner. You can claim Medicare rebate if you are eligible however please bring your
referral information.
Cancellation Policy
We are a busy practice. In order to provide a quality service, if you need to cancel or
postpone your appointment, we ask that you give least one full business days notice. If you
provide us with less than one full business day’s notice and we cannot fill your appointment
time with another client, you will be charged 50% of your full consultation fee. If you fail to
attend and provide no notice, unless there is a reasonable explanation, you will be charged
100% of the consultation fee if you do not attend. We will provide you will reminders,
however, it is your responsibility to manage your appointment times.
Australian Psychological Society (APS) Charter for Clients of Psychologists
Attached to this form, you will find a charter developed by Australia’s national professional
organisation for psychologists, the APS. This charter outlines your rights as a client of a
psychologist, including what you can expect from your provider here at MindWare.
Please read this charter carefully and, if you request, your provider can make a photocopy
for you to take home with you.
Emergency and After Hours Coverage
Normal operating hours for the clinic are Monday through Friday, 9:00AM through
5:00PM, excluding public holidays. When there is no one available to take your phone call,
you may leave a confidential message on the clinic’s answering machine.
The clinic does not have coverage for emergencies. In the case of an emergency, you should
contact your nearest hospital emergency department. Alternatively, you may call an agency
called Lifeline which operates a 24-hour telephone crisis counselling service on 13 11 14.
You are encouraged to share any experienced after-hours emergencies as soon as possible
with your provider.
PROVISION OF CLIENT CONSENT:
I/We have read the above information carefully and understand that:
1. All services at the clinic are provided by practitioners and staff at Mindware
Psychology.
2. There are circumstances (outlined above) under which the confidentiality of the
information I/we provide may be broken.
3. As part of the counsellor/provider’s training, session(s) may be recorded, but that I/we
will always be told in advance.
4. The clinic has no emergency or after hours coverage, but I/we understand where help
should otherwise be sought.
I/We also understand that I/we can withdraw from treatment here at the clinic at any time
without prejudicing any future treatment here.
CLIENT NAME (please print): _________________________________
CLIENT SIGNATURE: _______________________________________
DATE: ______ / ______ / _____
Optional consent
I consent to staff (including administration staff) leaving a text or voice mail message.
CLIENT NAME (please print): _________________________________
CLIENT SIGNATURE: _______________________________________
DATE: ______ / ______ / _____
