Client Information and Intake Form

Client Information and Intake Form
Just to advise that unfortunately at this stage there is no availability at all for new clients, however discharges do occur and so your contact details could be managed for contact when availability resumes.

Psychological Service

As part of providing a psychological service to you, Charles Lucas needs to collect and record personal information from you that is relevant to your situation such as, your name, contact information, medical history and other relevant information as part of the provision of psychological services to you. This collection of personal information will be a necessary part of the psychological assessment and treatment that is conducted.

Purpose of collecting and holding information

Your personal information is gathered as part of your assessment and treatment and is kept securely, and in the interests of your privacy, used only by your psychologist and the authorised personnel of the Practice (as necessary). Your personal information is retained in order to document what happens during sessions and enables the psychologist to provide a relevant and informed psychological service to you. A more detailed description is provided in the Practice's "Privacy Policy for the Management of Personal Information". The Privacy Policy contains information about how to access and seek correction of your personal information if required, and how to lodge a complaint about the management of your personal information.

Access to client information

You are entitled at any stage to access your personal information subject to exceptions in the relevant legislation. Charles can discuss the different possible forms of access with you.

Disclosure of personal information

All personal information gathered by Charles Lucas during the provision of the psychological service will remain confidential except when:

  • It is subpoenaed by a court or,
  • failure to disclose the information would in the reasonable belief of Charles Lucas place you, or another person, at serious risk to life, health or safety, or your prior approval has been obtained to,
  •  provide a written report to another professional or agency.
  • discuss the material with another person (parent, employer, health provider)
  • disclose the information in another way, or,
  • you would reasonably expect your personal information to be disclosed to another professional or agency (GP) and disclosure of your personal information to that third party is for a purpose which is directly related to the primary purpose for which your personal information was collected, or,
  • disclosure is otherwise required or authorised by law.


The consultation is usually around 50 minutes in duration and Medicare rebates are available if you have been referred by your GP and have a Mental Health Care Plan in place. If payment is covered by a third party payer then the organisation will be billed separately. Charles Lucas uses Halaxy to manage the fees and this software, supported by the Federal Government, encrypts all information regarding credit/debit card details so you can be assured of security in regard to this information, and indeed, any other information you provide.

Letters and Reports

Please note that requested letters and reports are not provided as part of the sessional fee itself and have to be funded additionally. This fee can be negotiated with Charles Lucas during the sessional time.

Cancellation Policy

If, for some reason, you need to cancel or postpone your appointment, please give at least 24 hours notice to enable the session to be offered to someone on the waiting list. Once you have made an appointment that time is reserved for you and cancelling without giving 24 hours of notice, or missing the appointment altogether, will incur an administrative fee of $66.00, in contrast to the usual practice of forfeiting the entire sessional fee. This fee must be settled prior to any further appointments being scheduled.   

Workers Compensation Details

General Practitioner

Please Note: You must have a current Mental Health Care Plan in place to claim a rebate.

Client Medicare Claiming Details

I request and authorise Healthkit Pty Ltd to enable online Medicare rebate claiming by registering and storing the following information.

By submitting this form I declare that the information on the form is correct and I acknowledge that I have read and understood the terms, conditions and mutual obligations of service engagement.

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