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Your Information

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Name *

First

Last

Date of Birth *

Gender *

Mobile Number *

Home Number *

How did you hear about Kinexus Psychology? *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Alternate address *

Guardian details (for children under 18yo) *

Emergency Contact

Please provide one alternate contact in case of emergency.

Emergency Contact *

First

Last

Contact Number *

Relationship *

Medicare and Health Fund Details

Please provide Medicare card details if you have a GP Mental Health Care Plan would like us to claim Medicare on your behalf. Please make sure that you have registered your bank account details with Medicare.

Medicare Number (include IRN) *

Expiry date *

Treating Doctor and Medical Practice *

PSYCHOLOGIST – CLIENT AGREEMENT
Purpose of collecting and holding information
Kinexus psychology is committed to ensuring that personal information collected is dealt with in accordance with the Information Privacy Principles contained in the Information Privacy Act 2009. As part of providing a psychological service to you, Kinexus Psychology will need to collect and record personal information from you that is relevant to your situation as part of the assessment, diagnosis and treatment of your condition. The information gathered is seen only by the psychologist, and is retained in order to document what happens during sessions, and enables the psychologist to provide a relevant and informed psychological service. You do not have to give all your personal information, but without the relevant information, this may mean that Kinexus Psychology may not be able to provide psychological services to you.

Access to Client Information
At any stage you as a client are entitled to access to the information about you kept on file, unless the relevant legislation provides otherwise. Your psychologist may discuss with you appropriate forms of access.

Confidentiality
All personal information gathered by the psychologist during the provision of the psychological service will remain confidential and secure except where:
It is subpoenaed by a court, or Failure to disclose the information would place you or another person at serious and imminent risk; or Your prior approval has been obtained to provide a written report to another professional or agency. eg. a GP or a lawyer; or discuss the material with another person, eg. a parent or employer; or if disclosure is otherwise required or authorised by law.

Fees
The current fees recommended by the Australian Psychological Society (APS) are set at $238.
The cost of a standard consultation (usually 55 minutes) is $200, which is payable at the end of the session by cash, or EFTPOS. Any rebate will be pay directly to your account.

Cancellation Policy
If, for some reason you need to cancel or postpone the appointment, please give me at least 24 hours notice, otherwise you will be charged $100 for the cost for the session.

Charter for Clients of Psychologists
The Charter explains your rights as a client of a psychologist (https://www.psychology.org.au/Assets/Files/APS-Charter-for-clients.pdf)

Crisis Service
Kinexus Psychology is unable to provide out of hours crisis service. If you are in crisis and need help urgently, please call: i) Lifeline 13 11 14; ii) Beyond Blue 1300 22 4436; iii) Kids Help Line 1800 55 1800;

I have read and understood the above Psychologist-Patient agreement. I agree to these conditions for the psychological service provided by Kinexus Psychology.

I have read and consent *

Yes I would like more information and to discuss further

I give my consent for Kinexus Psychology to complete reporting requirement as part of the Mental Health Care Plan. *

Yes No Not applicable

I provide consent for Kinexus Psychology to speak to my child's school and teachers to coordinate care. *

Yes No Not applicable

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I have read and understood the above Psychologist-Patient agreement. I agree to these conditions for the psychological service provided by Kinexus Psychology.

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