[STAGING] Personal Details and Consent Form – PsychSolutions Health and Wellbeing

Personal Details

Given Name(s) *

Family Name *

Mobile Phone *

Home Phone

Email Address *

Date of Birth *

Residential Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Postal Address

Same as previous

Postal Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Do you give permission for us to post mail to the above address (i.e accounts) *

Yes
No

Do you give permission for us to send emails to the email address provided? *

Yes
No

Do you give permission to send text messages to your mobile to confirm appointments? *

Yes
No

Referral Information

How did you first hear about us?

What service are you utilising? *

Client Agent Details

Case Number

Agent Manager Name

Agent Manager Contact Number

Agent Manager Contact Email

Client Medicare Details

Client Medicare Card Number *

Number before Client's Name *

Client card valid until *

Is there someone else claiming with Medicare on behalf of the client? *

Yes
No

Claimant Medicare Details

Claimant Name

First

Last

Claimant Date of Birth

Claimant Medicare Card Number

Number before Claiment's Name

Claimant card valid until

Emergency Contact

Emergency Contact Name *

First

Last

Emergency Contact Mobile Phone *

Emergency Contact Relationship

Credit Card Authority

Card Details

Visa/Mastercard

Card Holder Name *

As shown on card

Card Number *

Expiry Date *

As shown on card

CVN *

Consent to Third Parties

Permission to liaise with third parties during your treatment? *

Yes
No

Eg. Your GP, Insurance Company, Psychiatrist etc

Consent to Practice Policy

I agree to the Practice Policies *

I agree to the Practice Policies

PsychSolutions are committed to improving the health and wellbeing of our clients. We see it as essential to deliver best practice ethical standards in all areas of our business. We also request our clients understand and follow our Practice Policies including our General Guidelines. Please read and understand our Practice Policies.

I agree to the Telehealth Consent Policy *

I agree to the Telehealth Consent Policy

Please read and understand our Telehealth Consent Policy.

I agree to the Cancellation Policy *

I agree to the Cancellation Policy

If, for some reason you need to cancel or postpone your appointment, please advise us at least 24-hours prior your appointment. For cancellations, ‘no shows’ or changes inside the 24 hours’ notice, PsychSolutions will charge a cancellation fee. Missing an appointment leads to lost sessional income for us and you will be charged the full fee according to our fee schedule. The reason for this charge is due to a high demand for our services and in respect of people waiting to be seen. Your appointment could have been allocated to someone else with enough notice. Cancellation fees are also charged in respect to our psychologists who still need to be paid whether you attend or not. An account for the cancellation charge will be sent to you if, after failed attempts of contacting you via phone or email, the fee remains unpaid. Cancellation fees must be paid before another booking can be taken.

Please read and understand our Cancellation Policy and Credit Card Management Policy.

Consent to Authority

I understand my credit card will be charged upon booking my first appointment if a new client or on the day of my scheduled appointment if an existing client *

I understand my credit card will be charged upon booking my first appointment AND on the day of my scheduled appointment

A booking fee of $100 will be charged upon booking and this amount will be deducted from the total fee of your appointment

I understand my credit card will be charged on the day of my scheduled appointment *

I understand my credit card will be charged on the day of my scheduled appointment

I understand my credit card will be charged FULL FEE if late cancel / no show as per PsychSolutions Credit Card Management Policy *

I understand my credit card will be charged FULL FEE if late cancel / no show as per PsychSolutions Credit Card Management Policy

Please read and understand our Payment Terms Policy and our Credit Card Management Policy

I authorise PsychSolutions to securely store and charge my credit card. *

I authorise PsychSolutions to securely store and charge my credit card.

Signature *

Date *

Personal Details and Consent Form

Please complete the form below and one of our friendly staff will contact you to arrange an appointment.