Personal Details and Consent Form

Personal Details

Given Name(s) *

Family Name *

Gender Identity *

Pronouns

Mobile Phone *

Home Phone

Email Address *

Date of Birth *

Is the client under 18 years of age? *

Yes
No

What is your child’s living situation? *

Please specify if "Other" is selected *

Details of child-access arrangements, are there current Court Orders in place? *

Yes
No

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

If you are attending our Orange office (a double story building) are you comfortable with stairs?

Yes
No

Thanks for letting us know, we will arrange for a downstairs room to be available.

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

Parent/Guardian Details

Name *

First

Last

Date of Birth *

Medicare Details for Parent/Guardian

Parent/Guardian Medicare Card Number *

Number before Parent/Guardian *

Parent/Guardian card valid until *

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

Emergency Contact Consent

I understand that PsychSolutions has a professional and ethical duty of care to act to protect my safety and the safety of others.
I consent to PsychSolutions contacting the person I have listed as my emergency contact if there is a serious risk of harm to myself or others, or if it is necessary to respond to a medical or psychological emergency and I am unable to seek help or provide consent at that time.
I understand that any contact with my nominated emergency contact will be limited to information needed to manage the immediate risk and keep me or others safe.

Yes, I consent
No, I do not consent

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 Separated Parents Policy *

I agree to the Separated Parents Policy.

Please read and understand our Separated Parents Policy.

I agree to the Attendance Policy *

I agree to the Attendance 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 Attendance 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 Policy and Attendance Policy *

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

Clear Signature

Date *

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