Client Information (Child/Adolescent)

(Child's) First Name *

(Child's) Last Name *

Date of birth *

Gender

Email Address *

Child's phone number (optional /if applicable)

Street Address *

Suburb *

Postcode *

Emergency Contact full name *

Emergency contact phone number *

Please indicate the relationship between the emergency contact and the child *

Please outline the supports needed for your child: *

Parent/Guardian Details

Parent / Guardian 1

Parent / Guardian 2

Parent/Guardian 1: Full Name *

Parent /Guardian 2: Full Name *

Parent/Guardian 1: Phone *

Parent / Guardian 2: Phone *

Parent/Guardian 1 Email *

Parent/Guardian 2 Email *

Parent/Guardian 1: Relationship to Child (i.e. Mother, father, guardian) *

Parent/Guardian 2: Relationship to Child (i.e. Mother, father, guardian) *

Parent/Guardian Consent

For the purposes of obtaining consent for psychological services, it is important for us to understand the nature of the parents/guardians relationship. Please indicate which of the following applies: *

Couple togetherSeparatedWidowedOther (please specify below)

If other please provide a description of your circumstances

Are there current court orders in relation to parenting agreements? *

Yes (please provide copy below)No

Please upload any relevant parenting or court orders relating to your child

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PAYMENT INFORMATION

Please indicate who will be paying for psychology services? *

If Other, please provide a description below

APPOINTMENT REMINDERS

NB: Our practice management system only allows for SMS appointment reminders to be sent to one mobile number. Please indicate below the PRIMARY mobile number SMS appointment reminders can be sent to.

Mobile number for appointment reminders (no spaces) *

Medicare Details

Complete the following section if you have a Mental Health Treatment Plan from your GP and will be using your Medicare sessions for psychology services.

NB: If you are seeing a provisional psychologist or engaging psychological assessment services, you do not need to complete this Medicare section.

Child's Medicare number (no spaces)

Child's Medicare individual reference number

Claiming Medicare Rebates as an Alternate Claimant.

For parents / guardians to receive the Medicare rebate, please indicate who will be claiming rebates and provide details below:

Which Parent/Guardian will be claiming the Medicare rebate? *

Parent/Guardian 1Parent/Guardian 2Both Parents/Guardians

Parent /Guardian 1 Alternate claimant name (as it appears on Medicare card) *

Parent /Guardian 2 Alternate claimant name (as it appears on Medicare card)

Parent/Guardian 1 Medicare number (no spaces) *

Parent/Guardian 2 Medicare number (no spaces)

Parent/Guardian 1 Medicare individual reference no. *

Parent/Guardian 2 Medicare individual reference no.

Parent/Guardian 1 Date of Birth *

Parent/Guardian 2 Date of Birth

Do you have a Pension or Heath Care Card?

Pension/ Health Care Card Number:

Name of person completing this information form: *

Date *

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