Intake Form

Client - First Name *

Client - Last Name *

Client - Date of Birth *

Is the client under 18 *

Yes No No and Supported by parent for services

Client - Gender

Client - Identity information that's important for us to know

Contact - Parent or Guardian *

Client Phone Number *

Parent Phone Number *

Client Email Address *

Parent Email Address *

Address - Client *

Kinder/School/Uni/Workplace of Client *

Grade Level at School (if relevant)

If seeking assessment, have you spoken to us about costs? *

Yes (we will book you in!)No or Unknown (we will follow up before booking appointments)

Reason for Referral (specific needs/goals) *

Key concerns *

Previous reports/assessments/letters (upload or email newenquiries@patc.com.au)

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Medical Conditions/Diagnoses (including mental health and Allergies)

Medication and Dosage (if known)

Sensory / Accessibility needs while at PATC (lights off, prefer to wait in car, in a wheelchair etc)

Medical/Allied Health/Other Supports

Other Details

Is the client an NDIS Participant? *

YesNo

Management *

Self ManagedPlan ManagedNDIA Managed (we cannot provide services)

Plan Manager *

NDIS participant number

Support Coordinator

NDIS Plan (upload or email newenquiries@patc.com.au)

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Consent for Services

Are you the client? *

Yes No - YOU CANNOT CONSENT, please have the client complete this form

Are you the Parent or Legal Guardian of the Client *

Yes No - YOU CANNOT CONSENT, please have their legal guardian or parent complete this intake form

Allied Health Service - Assessment and Therapy Consent

"Allied Health" as used here describes the following professional services:
Psychology, Occupational Therapy, Teachers, Speech Pathology, Counselling, Play Therapy, Excercise Physiology, Social Work and Allied Health Assistants.

"Allied health professional" as used here describes Psychologist, Teacher, Counsellor, Occupational Therapist, Play Therapist, Excercise Physiologist, Speech Pathologist and Social Worker.

Allied Health Service – Therapy and Assessment

As part of providing an allied health service to you Psych Assessment and Therapy Centre needs to collect and record personal information from you or your child that is relevant to your situation, such as your name, contact information, medical history and other relevant information as part of providing allied health services to you. This collection of personal information will be a necessary part of the allied health assessment and treatment that is conducted.

Purpose of collecting and holding information

Your personal information is gathered as part of your assessment and treatment is kept securely and, in the interests of your privacy, used only by your allied health professional and the authorised personnel of the practice (as necessary). Your personal information is retained in order to document what happens during sessions and enables the allied health professional to provide a relevant and informed allied health service to you.

Consequence of not providing personal information

If you do not wish for your personal information to be collected in a way anticipated by this form Psych Assessment and Therapy Centre may not be in a position to provide the allied health service to you. You may request to be anonymous or to use a pseudonym, unless it is impracticable for Psych Assessment and Therapy Centre to deal with you or if Psych Assessment and Therapy Centre is required or authorised by law to deal with identified individuals. In most cases it will not be possible for you to be anonymous or to use a pseudonym, however if Psych Assessment and Therapy Centre agrees to you being anonymous or using a pseudonym, you must pay consultation fees at the time of the appointment.

Access to client information

At any stage you are entitled to access your personal information kept on file, subject to exceptions in the relevant legislation. The allied health professional may discuss with you different possible forms of access at your request.

Disclosure of personal information

All personal information gathered by the allied health professional during the provision of the allied health service will remain confidential except when:

it is subpoenaed by a court;

or failure to disclose the information would in the reasonable belief of Psych Assessment and Therapy Centre place you or another person at serious risk to life, health or safety;

or your prior approval has been obtained (verbal permission) to

a) provide a written report to another professional or agency. e.g., a GP or a lawyer; or

b) discuss the material with another person, eg. a parent, employer or health provider; or

c) disclose the information in another way; or you would reasonably expect your personal information to be disclosed to another professional or agency (e.g. your GP) and disclosure of your personal information to that third party is for a purpose which is directly related to the primary purpose for which your personal information was collected;

or disclosure is otherwise required or authorised by law.

Your personal information is not disclosed to overseas recipients, unless you consent or such disclosure is otherwise required by law. Your personal information will not be used, sold, rented or disclosed for any other purpose.

We are a multidisciplinary centre with different practitioners from different disicplines, when working with Psych Assessment and Therapy Centre, you consent to your/your child's information being shared with the team when in your best interests and also when working with multiple clinicians.

Client Safety

Parents or guardians of a client with a medical condition who may require emergency management or medication during their session (asthma inhaler, Epipen, seizure assistance etc) are required to stay within the building at all times during their child's session unless otherwise discussed. No food is to be eaten in the waiting room.

For clients aged 16 and under, a parent or guardian should be available at all times during the scheduled session. In the event that the parent/guardian must leave the rooms, they are required to return fifteen minutes before the end of the session. No children under the age of 12 are to be left unattended in the waiting room. There must be a parent/guardian to actively supervise at all times.

Consent by non-client parent (child clients)

If it is made known to us that one parent does not consent to their child accessing allied health services or if it becomes known to us during treatment that a non-client parent does not consent, then treatment will cease. We can instead provide services to the consenting parent to help support their child.

Expectations of interactions and attendance.

At Psych Assessment and Therapy Centre, we have the following expectations of clients and anyone attending our space with clients:

Respectful Communication with staff and other clients: including face-to-face, over the phone, email and other.
When at Psych Assessment and Therapy Centre: behaviour not tolerated that others in the space may find offensive or discriminatory.
No taking photos, videos or voice recordings when in the building or in appointments, unless discussed and approved by practitioner.

We have a no-tolerance policy for bullying or disrespectful behaviour towards our staff which will result in a ceasing of services.

Limitations of Supports

At Psych Assessment and Therapy Centre, we are a small privately owned and operated business. By signing our consent form you acknowledge that:

When staff leave, reduce times or take on other tasks to differ their practice, we may not be able to provide you with ongoing support.
We work with best-fit clients who we are able to support within our scope of practice, and may not be able to provide you services despite signing consent or being on a waiting list.
Due to our codes of ethics, if there is a conflict of interest or dual relationship, we will cancel appointments with minimal notice despite you having been on a waiting list.

Please tick if you have read, understood and consent to consent form *

If you consent to the above conditions, please sign your Signature *

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Psych Assessment + Therapy Centre Fees

All services are charged in line with the NDIS Price Guide

Psychology Services $214.41 per hour
Occupational Therapy $193.99 per hour
Excercise Physiology $166.99 per hour
Social Work and Play Therapy $193.99 per hour
Speech Pathology $193.99 per hour
Allied health assistant $86.79 per hour

Fees are charged for

Direct appointments, face-to-face meetings or appointments, as well as telehealth appointments or phone appointments One hour appointments inlcude 45 minutes direct time with the client and 15 minutes note taking without the client at the end, pro rata for all other times (1.5, 2 hours etc).
Prior to accepting the referral: discussions with your or your/childs support coordinator in order to clarify the purpose of the referral. Planning and preparation prior to your initial appointment if necessary.
All phone and email communication, especially for extended emails. To avoid these charges please bring quories to sessions rather than emailing.
Writing of file notes and writing assessment reports for you and the NDIS.
NDIS review reports will be completed when requested by the client, parent, support coordinator or NDIS (LAC etc) and will be charged up to 2 hours.
Travel expenses: As per NDIS guidelines travel is billed as practitioner time as well as an additional fee of 90c for every km travelled. The 90c per km is to ensure staff are being compensated for their costs when travelling. Consent to fees includes consent for both aspects of the travel charge for all requested off-site appointments.
Multidisciplinary Meetings: For any clients who is supported by more than one practitioner at Psych Assessment and Therapy Centre, including allied health practitioners and therapy assistants, supports include 4 x per year professionals meetings for an hour unless otherwise notified. These will be billed per practitioner, at the practitioner rates. This is to ensure the best multidisciplinary practice and a collaborative and cohesive approach. Consent to fees includes consent to meetings, which are for professionals only and will not require parent/client attendance.

NDIS CLIENTS

you will immediately notify Psych Assessment and Therapy Centre if the participant’s NDIS Plan is replaced by a new plan or the participant stops being a participant in the NDIS; and
if self-managed or plan-managed, you will ensure sufficient funds are available to pay for sessions and, if not, you will take responsibility for the payment of outstanding fees.

Appointment Fees - Assessment

Psychological Assessment costs are available on request, please email newenquiries@patc.com.au

Please tick if you have read, understood and consent to all fees *

Please sign if you consent to the above fees *

Clear

Allied Health Service - Cancellation Policy

Fees for Cancellation of Appointments
No fees if appointments cancelled more than 48 hours prior. For Monday and Tuesday appointments cancellations need to be made by 12pm the Friday prior.

If cancelled or no attendance within 48 hours full fees will be charged.

Appointment reminders may be sent via text message or email prior to appointment as a curtesy. Not receiving them is not a reason for non-attendance. If a cancellation fee applies an invoice will be sent via email and must be paid before future appointments are able to be rebooked. If consecutive non-attendance or late cancellations occur, we will require you to pre pay fees before future sessions or sessions may be cancelled

Please tick if you have read, understood and consent to the cancellation policy. *

Please sign if you consent to the cancellation policy *

Clear