Intake & consent form (INDIVIDUAL) PART A: YOUR DETAILS Name * First Name Last Name Email * Phone (###) ### #### Address Street, number, suburb, state and postcode Date of birth Gender: how do you identify? Are you currently employed? Yes (full-time) Yes (part-time) No Occupation Are you currently a student? Yes No Are you currently in a relationship? Please describe any relevant details (e.g. single, married, recently broke up, unhealthy relationship) Do you have any children? If yes, please provide any relevant information (e.g. how many, ages, live with me/don't live with me, etc) Next of kin details First Name Last Name Phone (next of kin) (###) ### #### Your relationship with your next of kin Emergency contact details First Name Last Name Phone (emergency contact) (###) ### #### Your relationship with your emergency contact PART B: MEDICAL/MEDICARE DETAILS Do you have a Mental Health Care Plan? Yes No, but intend to get one No, and don't intend to get one Not sure Medicare number (if you wish to claim Medicare subsidy) Medicare IRN (number in front of your name) Medicare expiry date Referring doctor (if using a mental health care plan): Referring doctor's practice name & address Please upload your mental health care plan and GP referral letter to the dropbox: https://www.dropbox.com/request/touOjU08tHTmbGdxARLk PART C: HEALTH HISTORY How would you describe your current physical health? Poor Unsatisfactory Satisfactory Good Excellent Please list any specific physical health problems you are currently experiencing. Have you ever been diagnosed with a mental health condition? If yes, please list below your diagnosis, who diagnosed you and when. Before now, have you ever sought support from a mental health professional (e.g. psychologist, counsellor, psychiatrist)? If yes, please describe any relevant information. Have you ever taken any medication for mental health reasons? If yes, please list the medication, whether you are currently taking it and for what reason. Do you have family history of mental health problems? Please describe any relevant information below. PART D: REASON FOR SEEKING SUPPORT Please describe your main reason for seeking support now. Is there any relevant personal or family history or current conditions that may be impacting on your mental health (e.g. family illness, conflict, migration, etc) CONSENT FORM Collection of Personal Information Personal information relevant to your current situation is collected and recorded as part of providing psychological assessment and treatment. Record Keeping The psychologist may take notes during the session and will make a record of your assessment and treatment following the session. Accurate record-keeping by psychologists is an ethical and legal requirement. Records will be securely stored in a password-protected location. Upon request, you may access the material recorded in your file, subject to the exceptions outlined in National Privacy Principle 6. Limits to Confidentiality All personal information collected or recorded by the psychologist will remain confidential, except in the following circumstances: 1. Failure to disclose the information would place you or another person at risk of harm, 2. The information is subpoenaed by a court, 3. Your prior approval has been obtained to provide a written report to a professional or agency, e.g. a GP or a lawyer, or, to discuss the material with another person, e.g. a family member. Please note that as part of the Medicare Better Access Scheme, psychologists are required to write progress reports to your GP. This is to ensure your continued eligibility for Medicare rebate and your GP's involvement in your treatment. Cancellation Policy/Late Cancellation Fee A 48-hour notice is required for all cancellations. Cancellations made without 48 hours notice will incur a late cancellation fee of $50. Cancellations made without 24 hours notice will incur a late cancellation fee equal to the full cost of the session. Limitations of Service This service is not intended for emergencies, and the psychologist may not always be available at short notice or outside regular consultation hours. If you require emergency assistance, please consult your psychologist for details of alternative services. Requests for support letters or psychological reports Fees for psychological reports vary based on their nature and scope. Upon request, you will be provided with a quote. Please note that a minimum of 7-14 days notice is required to prepare support letters, and additional time may be needed for court reports.. Consent Please print your name below and check the checkbox to indicate your agreement to these conditions for the psychological service provided by the psychologist at Shikha Gray Psychology. * I have read and agree with these conditions * Yes No Thank you!
