Registration & Consent Form (Counselling)

Client Information

Are you completing this form as a Parent/Guardian for the client who is under 18 years of age? *

Yes (If so, please provide the following information about your child)No

Title

Preferred Name

Pronouns

Gender

First Name *

Last Name *

DOB: day/month/year *

Mobile Number *

Home Number

Email Address *

Residential Address *Include: Number, Street, City, State, Post Code

If you are a guardian completing this form, please provide your:

First and Last Name

Phone Number (write 'N/A' if same as above)

Email (write 'N/A' if same as above)

Residential Address (write 'N/A' if same as above)

Relationship to child

DOB: day/month/year (C)

Health Information

Please note that if you have been issued a Referral/Mental Health Care Plan, your Medicare card information is required to Immersive to submit a claim on your behalf allowing reimbursement for the initial 6 (and if approved by your GP) subsequent 4 sessions on your plan within a single calendar year.

Please enter the Medicare details for the individual recieving treatment.

Medicare Number *

IRN (POSITION ON MEDICARE CARD) *

Expiry Date: MM/YYYY *

If you are a guardian completing this form for your child, please enter your Medicare details if they have not yet been issued their own Medicare card:

Medicare Number (Guardian)

IRN (Guardian)

Expiry Date (Guardian)

For private health insurance rebates, please contact your health insurance provider for submission instructions.

Private Health Fund Name

Private Health Membership Number

How can we help

Please enter a brief description of your concerns so that we can screen for client match for example., depression, anxiety, relationship therapy OR individual relationship/family concerns, family therapy, trauma/PTSD, emotional concerns and personality concerns. Providing information here also assist with first sessions and helping the pracitioner guide your care right from the very begining.

We recommend that you phone the office for assessment bookings.

Please expand on the above response/s selected

Sharing some background information will help us connect you with a psychologist who best suits your needs and ensure that your initial session is focused and productive.

Please note: if you have been admitted to a hospital in the last 3 months for a mental health concern, if you wish for invoices to be sent to your insurer, Work Cover or my NDIS plan manager, if your appointment relates to psychological assessments, eating disorders, borderline personality disorder, bi-polar disorder or schizophrenia you need to phone the office instead of making an online appointment so that the practice can make the appropriate booking with the right clinician and be informed of the correct paperwork required for the booking. Clinicians' capacity to assist complex clients varies according to their caseload.

Emergency Contact Details

Name (first and last) *

Emergency Contact Phone *

Relationship to you *

Referral

Do you have a Referral? *

If you have not yet provided your referral and/or Mental Health Care Plan, please upload these here here. A Medicare reimbursement can only be processed if we have the appropriate valid referral on file.

f you have a Mental Health Treatment Plan (MHTP) referral form your GP, it will allow you to receive a rebate ($136.35 for a Clinical Psychologist and $92.90 for non-clinical psychologists). Please upload, email or bring the referral, MHTP and your Medicare card to the first session to be able to access the rebate.

Don't have one? That's ok:

If you do not have this yet, you can submit later via email to admin@immersivepsychologygroup.com

If you do not have a regular GP, you are welcome to use Doctors on Demand, a 24-hour online Telehealth GP service where appointments are available 7 days a week.

If you would like a local GP recommendation or a Eating Disordered Informed GP, please email us on the above email address or call: 0400 428 593.

You may upload your Referral here.

Browse

We usually process rebates for you on the day of your sessions but please allow a few days for processing to be completed. The MHP allows up to 10 Medicare-rebated sessions per calendar year. These are provided with an initial 6 sessions then a further 4 after a 6 session review is conducted by your GP. While we take care to inform you of the availability of this rebate and offer the service to process rebates, ultimately it is your responsibility to check and keep track of the number of sessions you have. We cannot be held responsible for any issues with rebates provided by Medicare.

Initial Appointment Deposit & Card Details

This non-refundable $50 new client booking fee will be deducted from your initial session fee. This means that your initial session will incur an out-of-pocket cost of $250 ($300 minus $50 deposit). All subsequent sessions are $260. If you are experiencing financial hardship please consult with our administrative staff to discuss potential alternative options.

Payment Details *

Please provide a $50.00 deposit for your initial session. The amount will be deducted from your first appointment invoice. Please note: the practice's preferred payment method is direct debit, and cash is not accepted.

Our Terms & Conditions, Privacy Policy & Information Collection Policy

Session Fee Policy (Missed/Non-attended/ Rescheduling and Cancellation): Therapy works best when you are committed to the process. We encourage you to keep your appointments via Video/Phone or in person to avoid delays in booking new ones and to speak with our team members at Immersive if you have concerns about therapy. When scheduling your appointments, please ensure you choose a time that you can commit to attending. If you fail to attend your appointment, or if you cancel orreschedule the session within 2 business days (Monday-Friday only, excluding Public Holidays) of its occurrence, you will be charged the cost for up to the full cost of the session. Medicare rebates cannot be claimed on fees for non-attendedappointments. Standard fee sessions are $260.00. Our current fee schedule can be found here: https://www.immersivepsychologygroup.com/faq/fees-rebates/

Payment and handling: payment of the $50 new client booking fee (only 1 fee is charged for the new booking even if you book more appointments). This fee is non-transferable or refundable and my appointment will be canceled if the booking fee is not received promptly and/or this form is incomplete 48 hours before your inital appointment. Telehealth appointments are charged 48 hours before your booked appointent, if funds are not available, we will attempt to contact you, however the appointment will be canceled if payment can not be completed. In person sessions will be billed on the day of the appointment.

Additional sessions, support between sessions and fees: If you require clinician contact between sessions please contact reception to arrange an additional appointment, this can be either an in-person/phone/video call with the psychologist that is billed at the pro-rata sessional rate if shorter in duration. Phone calls regarding your child's progress in therapy between scheduled sessions are also available and billed at the pro-rata rate. Family/couple/child/parent confidentiality applies to individual sessions so confirm the appointment appropriateness with the psychologist prior to booking an individual session. Contact reception to be added to our waitlist.

Consultation with other professionals/teachers/document review and reports/treatment updates (Non-Medicare/DVA review letters): Phone calls, reports, treatment update letters and consultations with other professionals for assessment or clinical related communication will be billed at the pro-rata rate. Documents and emails are reviewed in session or billed at the sessional rate, and should be emailed to admin@immersivcepsychologygroup.com and booked in advance.

Psychology services: As part of providing a service to you, Immersive Psychology Group Pty Ltd needs to collect and record personal information from you that is relevant to your situation, such as your name, contact information, medical history and other relevant information as part of providing services to you. This collection of personal information will be a necessary part of the assessment and treatment that is conducted.

Bookings for children aged 12 years or younger: Please note that the parent/guardian must attend the initial session. In light of exceptional circumstances, if the parent/guardian would like to change this to the second session, please contact reception to make the relevant booking.

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 practitioner and the authorised personnel ofthe practice (as necessary). Your personal information is retained in order to document what happens during sessions andenables the practitioner to provide relevant and informed service to you. If you change practitioners, this information will then be made available to the next practitioner for the same purpose, with your documented consent.

Consequence of not providing personal information: If you do not wish for your personal information to be collected in a way anticipated by this letter or the Privacy Policy, Immersive may not be in a position to provide a service to you.

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. For queries about accessing your information, please speak to your practitioner, or contact IPG admin team.

Disclosure of personal information: All personal information gathered by practitioners during the provision of the service will remain confidential except when:

It is subpoenaed by a court, or disclosure is otherwise required or authorised by law; or
Failure to disclose the information would in the reasonable belief of the practitioner place you or another person atserious risk to life, health or safety; or
Your prior written approval has been obtained to:

Provide a written report to another professional or agency. e.g., a GP or a lawyer; or
Discuss the material with another person, eg. a parent, employer, health provider or third-party funder; or
Disclose the information in another way; or
Disclose to another professional or agency (e.g. your GP) and disclosure of your personal information to that third partyis for a purpose which is directly related to the primary purpose for which your personal information was collected.

Your personal information is not disclosed to overseas recipients, unless you consent, or such disclosure is otherwise requiredby law. Your personal information will not be used, sold, rented, or disclosed for any other purpose. In the event that unauthorisedaccess, disclosure or loss of a client’s personal information occurs, IPG will inform you and will use all reasonable endeavours to minimise any risk of consequential serious harm.

Changes to this policy: Immersive may update this Policy from time to time and any updated versions of this Policy are available on the IPG website. If we make any changes to this Practice Policy that materially affect our practices with regard to the Personal Information we have collected from you, we will endeavour to provide you with notice in advance of such changeby highlighting the change on the Site, or where practical, by emailing you.

Telehealth Appointment Important Information: No one is permitted to record the call without written consent of all parties involved.

Emergency/Urgent Matter: Please be advised that Immersive is not an emergency service provider and does not provide crisis services. If you are in a crisis or in need of immediate assistance please call 000, or go to your nearest emergency department. For immediate support prior to this appointment please contact Lifeline 131114.

If after reading this form you are unclear about any of the information provided, please discuss this with your practitioner prior or in your first appointment. For more details on our terms and conditions, or privacy policy please click on each link.

Consent

How did you hear about us? *

I understand that most clients require 12 to 20 sessions (although this varies and the final assessment must be made with you and your psychologist) and that I must book at least 4 sessions ahead on a weekly basis initially. Immersive has a duty of care to be able to provide an adequate service which means follow-up appointments are paced in a meaningful way. I know that the psychologist understands if I do not wish to continue after the initial consultation and will facilitate transfer to another more suited psychologist or cancel future booked appointments. *

I understand that appointments for psychological assessments must not be made online and need to be made through the Immersive office so that the psychologist can be matched to the reason for my report, my diagnosis, treatment history and deadline for the report. *

I understand that my online booking will be reviewed in line with the clinician's capacity for new clients and the provision of ongoing sessions to myself and their existing clients and that in some instances I may be asked to reschedule my initial appointment to a later date. I understand that I need to phone the office if I need immediate confirmation. *

I confirm that all the information I have provided is true, complete and accurate.
*

Please confirm you have read and agree to terms in our Psychology Practice Privacy and Consent Form detailed above, including appointment arrangements for clients aged 12 years or under.
*

I consent to receive SMS and email communication from Immersive (including appointment reminders and emailed receipts).

*

I consent to receive marketing and other communication from Immersive.

Date *

Signature *

Clear

Thank you for completing our registration and consent form. You will now be redirected to the client portal booking system to book your first appointment.

Booking further sessions: Most clients need around 12-20 sessions, with 50% needing 20 or more (with the final decision made between you and your psychologist), we recommend you book your blocks 4 to 6 sessions ahead (2 months) to ensure optimal consistency in therapy. Immersive has a duty of care to be able to provide an adequate service which means follow-up appointments are paced in a meaningful way. I know that the psychologist understands if I do not wish to continue after the initial consultation and will facilitate transfer to another more suited psychologist or cancel future booked appointments.

Book (online https://portal.coreplus.com.au/immersivepsychologygroup), or email ( admin@immersivepsychologygroup.com), or phone call (0400428593). Please also reach out if you'd like to go on the waitlist for a cancelled appointment.

Please note, although card details are taken when booking your appointment, no payment will be processed. Details are securely stored on our system for processing 2 days before your telehealth appointment, or on the same day as your in person appointment.

If you have any questions or concerns please don't hesitate to contact us:

Tel: 0400428593

Email: admin@immersivepsychologygroup.com

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