Client Details and Consent Form - Psychology All new Psychology clients, please complete this form for our records before your initial appointment. Client DetailsClient Name:*Client Date Of Birth*Client AgeGenderMaleFemaleLegal Guardian Name (for clients under 18):Contact Phone (Home)Contact Phone (Mobile)*Client Address*Email AddressMedicare NumberInclude reference numberCRN or NDIS NumberFor paediatric clients - are there any current court orders in place regarding custody and/or care for your child?If "Yes' please provide detailsYesNoOut Of Home Care (if applicable)Please provide the following information for any other guardians or case workers involved with your child. Please include organisation, case workers name, phone and email contact details, relevant placement history and indicate if the child is placed with you on a permanent or temporary basis.Consent DetailsPsychological Service*As part of providing a psychological service to you, your Psychologist will need to collect and record personal information from you that is relevant to your current situation. This information will be a necessary part of the psychological assessment and treatment that is conducted. You do not have to give all your personal information but if you don't, this may mean the psychological service may not be able to be provided to you. I agree I do not agree Purpose of collecting and holding information*The information is gathered as part of the assessment, diagnosis and treatment of the client's condition. The information is retained in order to document what happens during sessions, and enables the Psychologist to provide a relevant and informed psychological service. I agree I do not agree Storage of client information*All client information is kept securely. Information such as client demographics, attendance records and payment records can be accessed by any staff at All Abilities Therapy and Support Services. The clinical information gathered as part of the psychological assessment, diagnosis and intervention is seen and accessed only by the Psychologist, however remains the property of All Abilities Therapy and Support Services. I agree I do not agree Access to client information*At any stage, you as a client are entitled to access the information about you kept on file, unless the relevant legislation proves otherwise. The Psychologist may discuss with you appropriate forms of access. I agree I do not agree Authority to act*The undersigned confirm/s that he/she is the legal guardian/s for the above mentioned child and/or are authorised to act on behalf of the child in the capacity of authorising All Abilities in their management. I agree I do not agree Client over 18 Confidentiality*All personal information gathered by All Abilities Therapy and Support Services during the provision of the service will remain strictly confidential and secure except when, in the rare incidence: 1. It is subpoenaed by a court, or 2. Failure to disclose the information would place you, your child or another person at risk 3. Mandatory reporting relating to child abuse, family violence pr suicidal ideation is necessary; 4. Your prior approval has been obtained to discuss the matter with another person or provide a written report to another professional or agency; 5. Or if disclosure is otherwise required or authorised by law. As required, reports and diagnosis will be conveyed to any relevant professional and/or government authority deemed appropriate by All Abilities for the direct assistance of the client's management. The undersigned gives permission for All Abilities Therapy and Support Services to liaise with the following parties for the direct assistance of the child’s management All Abilities Therapy and Support Services National Disability Insurance Agency Paediatrician/Specialist/General Practitioner Other health professionals e.g. psychologist Educators e.g. schools Early Intervention services Family Members Fees*All Abilities accepts private payments, Health Insurance, Medicare Plans (for rebates), FaHCSIA Funding and NDIS Funding. Rates may vary depending on funding arrangements, please contact All Abilities to confirm relevant pricing structure. Please note Bulk Billed sessions are not available for Psychology services. Please indicate your payment method: Paying privately Health Insurance Medicare Rebated session NDIS Funding FaHCSIA Funding Other Cancellation Policy*Please be advised that the following cancellation fees apply to all clinic, home and school sessions: • Cancelling an appointment before 3pm the business day before the scheduled appointment - Free of Charge • Cancelling an appointment after 3pm the business day before the scheduled appointment OR failing to attend an appointment with no notice given – 90% of scheduled fee charged NDIS guidelines allow service providers to charge 6 hours worth of cancellation fees to your NDIS funding per year. Please be advised that any further cancellation fees incurred will not be able to be charged to your NDIS funding and will be payable by the Individual / Individual’s Representative. The Provider understands that people and/or their children get sick and so request you contact the clinic prior to the appointment and provide a medical certificate in order for the cancellation fee to be waived. A medical certificate is required to be supplied within 48 hours of the cancelled appointment. If you/your child is unable to make any scheduled appointment please call the office on 4731 3469. Please note that failing to attend two appointments within a 6 week period will result in the cancellation of any further scheduled appointments. Repeated cancellations within a 48 hour period (3 appointments within a 6 week period) will result in the cancellation of recurring appointments. You may call the office to reschedule appointments where there are times available. I agree I do not agree Where did you hear about us?* National Disability Insurance Agency School Pre-School GP Paediatrician Word of mouth Internet Brochure In-service/Forum Stall/Expo Other Newsletter* Yes No A quarterly newsletter is provided by All Abilities Therapy and Support Services, outlining any updates to our services including upcoming groups, networking and education opportunities, as well as blogs and resources written by our team of therapists. Do you give consent for All Abilities to email you a copy of our newsletter each quarter?Family InformationParent 1 Name:Parent 1 D.O.B:Parent 1 Occupation:Parent 1 Address (if different to client):Parent 2 Name:Parent 2 D.O.B:Parent 2 Occupation:Parent 2 Address (if different to client):Who lives at home?Siblings name and ages (for clients under 18):Main language spoken at home:Other languages spoken at home:School/Pre-School Information (if applicable)School/Pre-School name:Is your child placed in a support class?YesNoDays attending:Teacher name:Phone number:Email:Early Intervention Provider (if any):Teacher name:Phone:Diagnostic InformationDoes the client have a definitive diagnosis?YesNoIf yes, what was the diagnosis?Who was the diagnosis made by?When was the diagnosis made?Please provide details of any other health professionals involved in the client's care (include Specialists, Paediatricians, Allied Health Professionals and previous Psychologists)Please provide any information regarding previous assessments administered with the client and any resultsReferral InformationMain reasons for referral:What do you expect from us working with you?