New Patient Registration Form (child/adol ALL)

New Patient Request

Please fill out the form below
Patient's Name

First NameMiddle NameLast Name
Please select appointment preference
Date of Birth

MonthDayYear
Contact Number:

Area CodePhone Number
E-mail
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Have you been referred by a health practitioner (Please name)?
Does your referral include a Medicare Plan?
Do you have an NDIS Plan?
Parent's Name
Child's School and Grade
For separated families: Do you have sole or shared decision making regarding your child?
*If you have selected sole decision making, please provide copies of the relevant court documents.

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Cancelof
**For families in a shared decision making arrangement, please provide the email address of the other parent so we can send a confirmation email.

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Cancelof
Are there any court orders in place regarding your child (Please provide copies)?
***
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your Name

First NameMiddle NameLast Name
Information Statement

Fees:

· $280 for Jodie Wassner or $240 for Rachel Richardson, per 50 minute session payable at time of appointment (in- person or manual)

·      Patient requests for phone calls, emails, report reading or report writing incur a charge at the hourly rate after the first ten minutes.

·      Private Health fund rebates may apply (check with your individual fund)

·      Cancelled appointments will incur the usual fee ($280/$240), unless two full business day’s notice is provided to the clinic.

·      Multiple cancellations will subsequently require payment at time of booking and will preclude the patient from booking further appointments at the busiest times (out of school hours).

· Outstanding payments may result in the cancellation of booked appointments on future dates.

· Fees outstanding will incur a fee.

For patients under NDIS, the following applies:

·      Curious Kids Psychology only accepts NDIS plans that are Self Managed.

·      Payment is expected at the time of appointment.

·      Referrals under NDIS require the psychologist to report back to NDIS when requested.

For patients under a Medicare Plan, the following applies:

·      A Medicare rebate may be claimed for patients under certain Medicare Plans including Better Access to Mental Health Care, Chronic Disease Management and Helping Children with Autism Package (please bring your referral).

·      Referrals under Medicare require the psychologist to report back to your referring health practitioner.
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New Patient Request