Client Information

Consent Form and Intake Form

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 providing 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 management of personal information”, which can be obtained by contacting Charles Lucas. The Privacy Policy contains information about how to access and seek correction of your personal information, and how to lodge a complaint about our management of your personal information.

Access to client information

At any stage you are entitled to access your personal information kept on file, subject to exceptions in the relevant legislation. Charles will discuss with you different possible forms of access.

Disclosure of personal information

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

  1. it is subpoenaed by a court; or
  2. 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
  1. provide a written report to another professional or agency. e.g., a GP or a lawyer; or
  2. discuss the material with another person, eg. a parent, employer or health provider; or
  3. disclose the information in another way; or
  1. you would reasonably expect your personal information to be disclosed to another professional or agency (e.g. your 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
  2. disclosure is otherwise required or authorised by law.

 Fees

The cost of a consultation, usually around 50 minutes, is $150.00 which is payable at the end of the session. Medicare rebates are available if you have been referred by your GP and have a Mental Health Care Plan in place, and in these cases the rebate is $84.80 leaving a balance of $65.20. If payment is covered by a third party payer then the organisation will be billed separately. Charles Lucas uses Healthkit to manage the fees and this software, supported by the Federal Government, encrypts all information regarding credit card details so you can be assured of security in regard to this information and indeed, any other information you provide.

 Cancellation Policy

If, for some reason you need to cancel or postpone your appointment, please give at least 24 hours notice to enable Charles to activate the cancellation list or you may be charged the cost for the session.

If, after reading this form you are at all unclear about any of the information provided, please contact Charles prior to your appointment.

 

 

 

 

 

 

 Client Details

 

Given Name/s_____________________ Surname________________________

 

Mobile___________________________ Email___________________________

 

Address__________________________________________________________

 

 

Client Medicare Claiming Details

 

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

 

Medicare Number: _______________________________________________________

 

Reference Number: _______    Valid to:_______/________

 

Date of Birth: _____/________/_________

 

 

Client Credit/Debit Card Authority

 

Name on Card _________________________________

 

Card Number___________________________________

 

Expiry Date ______/________

 

I request and authorise Healthkit Pty Ltd ABN:62131908597 to debit payments from the nominated credit card identified below in accordance with this payments authority, the Terms of Use and the Credit/Debit Card Authority Service Agreement. I authorise Healthkit to debit funds from my debit/credit card identified above when I have an appointment with or am provided services by Charles Lucas Psychologist. I acknowledge that Healthkit Pty Ltd will appear on my statement.

 

Signature

By signing this Payment Authority, I declare that the information contained is correct. I acknowledge that I have read and understood the terms and conditions contained in this payments authority and the Credit/Debit Card Service Agreement, and agree to be bound by them.

 

 

___________________________________________ Date ______/________/_______

Signature of the nominated Account/Credit Car