Information supplied in this form is kept strictly confidential.

Please fill out this New Client Intake Form (below) before you attend your appointment. This form will be emailed directly to Ben French at Port Psychology.

Confidentiality

Information Security and Access

In the course of your treatment, personal information about you is collected to enable your treatment. All notes taken in the course of your treatment and all communications relating to your treatment becomea part of your clinical records. Your clinical records are stored electronically in your patient file, which you consent to as a patient of this practice. You have a general right to access your records (subject to some exceptions which mainly relate to privacy, health or legal considerations) and can request access to your records. Your request must be made in writing, after which your request will be discussed with you.

All information obtained during your treatment is kept confidential and secure, except when:

(1) It is subpoenaed by a court;

(2) Failure to disclose the information would place you or another person at risk of harm; or

(3) Your prior approval has been obtained to:

(a) provide a written report to another professional or agency—e.g. to a lawyer; or

(b) Discuss the material with another person—e.g. a parent or employer.

If you claim rebates from funding bodies, doctors and health practitioners may be required to provide summary reports to referring doctors, specialists and/or agencies regarding your progress. Health research using de-identified data may be undertaken by this practice, by funding bodies or by this practice’s technology providers, which you consent to as a patient of this practice.

Fees, Rebates and Cancellations

Fees are payable either using automatic payments or at the end of your appointment. When you make an appointment the whole appointment time is reserved for you. Please give as much notice as possible if you need to cancel or postpone your appointment. If you do not give at least 24 hours’ notice you may be charged the full appointment fee. If you are eligible for Medicare rebates, you can claim Medicare rebates automatically using this practice’s online Medicare rebates claiming service. Otherwise, you can take your invoice to a Medicare office at a later date to claim your rebates.

If you are eligible for Medicare rebates, you can claim Medicare rebates automatically using this practice’s online Medicare rebates claiming service. Otherwise, you can take your invoice to a Medicare office at a later date to claim your rebates.

By submitting the form below, I declare that the information on this form is correct. I acknowledge that I have read and understood the terms and conditions contained in this new client form.

 

Contact Details

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Fee Scale
To try and accommodate everyone fairly we have a sliding fee scale . Our fees are substantially lower than the Australian Psychological Societies recommended rate of $179 per session. Please tick the appropriate fee for your family.

Standard Fee $140 per session, rebate if applicable approx $85 ($55 gap fee)
Cognitive assessments (start from $450).
Educational assessments (start from $550).

If there are significant financial difficulties, there are a number of free services available in the area such as: community health, community mental health and Headspace. We do provide a no cost service via Healthy MInds and Victims of Crime referrals. More information on these referrals are located on the fees page.

Payment Information
Payment information will be stored on our practice management software and payments and rebates will occur automatically after each visit and an invoice and receipt will be emailed to you.


For medicare rebates we can give you a receipt to take to Medicare to claim the rebate or we can place them directly into your nominated bank account. Due to difficulties with the EFTPOS Terminal's reliability, we place them directly into your account via our practice management software, Healthkit.

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


Cancellation Policy
24 hour notice of cancellation is needed or late cancellation fee of $50 will apply. Government and non government agencies will be charged the full fee for the session.

 
 

By submitting this form, I declare that the information on this form is correct. I acknowledge that I have read and understood the terms and conditions contained in this new client form.

If this form won't send please scroll up and check that all required fields have been filled in (any errors are marked in red). Alternatively you can request a pdf copy of this form from Port Psychology - contact Ben French