Intake form

Thanks for your enquiry!
Thank you for contacting Wise Institute to request an appointment.

If you are new to Wise Institute or have not been in for more than 6 months then please complete these questions so we know how to respond to your request. For our current clients, feel free to contact our Admin team 02 9906 5199 (Mon - Fri, 8am - 6pm), Reception@wiseinstitute.com.au to book an appointment or you can ask them to send your confidential portal link so you can book online.

At Wise we take a collaborative approach in all aspects of our service. It is important to us that you are placed with a Psychologist who is well matched to assist with your concerns and who takes an approach that would work well for you.

The following questions help us to understand you, what has led to you seeking assistance and whether we have a psychologist who is well suited to you. It may take up to 15-20 mins to complete these questions. If you would prefer to provide this information over the phone or have any concerns about providing this information, please contact our Admin team or Intake Team on 02 9906 5198 (Mon - Fri, 9 - 5pm) or Intake@wiseinstitute.com.au

Once you complete this form, our Intake team will be in touch via phone or email to discuss whether we have suitable psychologists and their availability, or to suggest other services who may be better suited to your needs. They endeavour to make contact in under two business days so please note the times and days when you can take their call.

Here at Wise Institute, your privacy is of utmost importance. All information is managed securely and confidentially in accordance with our legal and ethical responsibilities, policies and requirements.

We value your time and will respond to your request as quickly as possible.

Many thanks, Wise Intake and Admin Team

Appointment Request
From completed

DayMonthYear
Date
Hour MinutesAM/PM Option
Myself regarding help for meMyself regarding help for me and my partnerAs a parent regarding help for my child
No previous appointmentOne or more appointments in the last 6 monthsNo appointments in the last 6 months
Current clients are welcome to call us on 02 9906 5199 or book through the portal so long as your last appointment was under 6 months ago. NB: Medicare rebates may not be available if it has been longer than 3 months since your last appointment so please phone us to check.
It's similar in nature to the work we were doing previously but it's got worse recentlyThis is unrelated to my previous work with Wise Institute.
PowerDiary Client ID
PowerDiary Client ID
Identified client
Contact Relationship
Client Age
Age group
Contact Name

First NameLast Name
Contact First Name
Contact Last Name
Contact Email
example@example.com
Contact Phone
Please enter a valid phone number.Format: 0000 000 000.
WL Notes
Your Details
First Name*
Last Name*
Date of birth*

DayMonthYear
Date
Age
Calc Age
Sex
Gender (I Identify as)
Email*
example@example.com
Mobile*
Please enter a valid phone number.Format: 0000 000 000.
Home Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Occupation
Marital Status

Your Current Partner's Details
First Name*
Last Name
Age
Date of birth

DayMonthYear
Date
Calc Age
Sex
Gender (They Identify as)
Email
example@example.com
Mobile
Please enter a valid phone number.Format: 0000 000 000.

Child's details
First Name*
Last Name*
Child's Age
Child's Date of Birth

DayMonthYear
Date
Child's Calc Age
Sex
Child's Email
example@example.com
Child's mobile
Please enter a valid phone number.Format: 0000 000 000.
Both parents (same household)Only with MumOnly with DadShared parenting arrangement / ordersOther
Child's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School / University name
School / University year
Child's mother
Who is this child's biological mother?
Child's father
Who is this child's biological father?
YesNoOther
Please briefly describe the parenting arrangements or situation your child currently resides in.
Mother's First Name*
Mother's Last Name
Mother's Email*
example@example.com
Mother's mobile*
Please enter a valid phone number.Format: 0000 000 000.
Mother's Address

Street Address

Street Address Line 2

CityState

Post Code
Father's First Name*
Father's Last Name
Father's Email*
example@example.com
Father's mobile*
Please enter a valid phone number.Format: 0000 000 000.
Father's Address

Street Address

CityState

Post Code

Referral Details
Seeing a psychologist can be done without a referral. However, this will mean you will not be able to claim any medicare rebates. Around half of our clients do have referrals and will seek rebates of some form.
My GPMy PsychiatristAnother psychologistOther medical profressionalA friend / family memberMy own research / onlineOther
What is their name and suburb / contact details?
eg Dr Smith, Jonestown
Referrer
Source
Who is your GP? Please provide their name and practice contact details / website. If you don't have a regular GP but have a practice you normally go to then any GP within that practice is fine. If you don't have a GP at all then please speak to our receptionist or your psychologist as it may be helpful to have a GP practice in place and if you're comfortable for us to keep them appraised of treatment progress.*
Are you / they currently taking any medications? Please include details of medication name, dosage, who prescribed it, how long you/they have been taking it and what was it prescribed to treat?
NoneMedicareNDISPrivate Health InsuranceOther
Medicare Referrals
Medicare can be complex to navigate, so we will try to help guide you as much as possible. We will ask for your referral and plans later, for now we will support you in understanding the various rules and processes to make this easier.

A MHCP (Mental Health Care Plan) is the most common type of Medicare referral, other types include plans for Eating Disorders, Chronic Disease Management and Helping Children with Autism are the most common. All of these plans require a referral from a GP or other specialist, please speak with your GP to determine your eligibility. GP's will generally need to schedule a 30 minute "long consult" to prepare a Care Plan.
MHCP / Better AccessEating Disorder PlanChronic Disease Management / Team Care ArrangementOther
Better Access / GP Mental Health Care Plans

This type of referral will typically entitle you to up to 20 rebated sessions in a calendar year (this will reduce to 10 from 2023 onwards). Rebates will be either $89.65 or $131.65 if you are seen by a psychologist or clinical psychologist respectively. Apart from the general rules above, the Better Access rules also include:
- This type of referral specifically excludes treatment for couples and families.
- The first referral can't be for more than 6 sessions and the GP will create a care plan which has no expiry date per se, but they will also issue a referral which does expire after 1 year. They will use one of these item numbers: 2700, 2701, 2715 or 2717; We will need the referral letter but you may also be given a multi page table format plan which is optional.
- Once we complete these 6 sessions your psychologist needs to write a report back to the GP who needs to do a review (aka re-referral). Typically this will take us a week to compile this report and the GP will not be able to issue a first "re-referral" until they receive our report nor sooner than 4 weeks from the creation of the original care plan.
- re-referrals will typically use the 2712 item number and generally will be for 4 sessions (max 10 under the non Covid psychology items)
- On completing these additional 4 sessions we will again be required to write back to the GP which will take a week;
- During 2022, and after reviewing our report and not sooner than 3 months from the first re-referral, the GP can issue a second re-referral under the Pandemic response items for a further 10 sessions;
- There is a limit of 20 sessions under Better Access in any one calendar year.
- If you have a 3 month gap in sessions, you will need to go back to your GP for a review.
- If you wait for a year to initiate sessions then you will need to go back to your GP for a review.
- If you see one psychologist for a couple of sessions then decide you want to see someone else you can, but your referral limits and annual limits don't reset.
- You don't need to book an appointment with your GP on the 1st of January, any available sessions will roll over from the previous calendar year.
See the following websites for more details:
1. https://www.servicesaustralia.gov.au/better-access-initiative-supporting-mental-health-care
2. http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=MN.7.1
Eating Disorder Plans

This type of referral will typically entitle you to up to 40 rebated sessions in any given 12 month period. Rebates will be either $89.65 or $131.65 if you are seen by a psychologist or clinical psychologist respectively. Apart from the general rules above, the EDP rules also include:
- This type of referral specifically excludes clients that don't meet specific criteria for an eating disorder which will be assessed by your GP.
- The first referral can't be for more than 10 psychological sessions and 20 dietetic sessions. They will use one of the 9025X item numbers; We will need the referral letter but you may also be given a multi page table format plan which is optional but recommended.
- Once we complete these 10 sessions your psychologist needs to write a report back to the GP who needs to do a first review. Typically this will take us a week to compile this report and the GP will not be able to issue a first "review" until they receive our report.
- reviews will typically be for a further 10 sessions (20 total to date).
- On completing these additional 10 sessions we will again be required to write back to the GP which will likely take a week;
- You will then need a "formal review". The GP will review progress as previously, however you will also need a review from either a psychiatrist or paediatrician. If they both concur that a higher intensity treatment is required then a further 10 sessions would be referred (30 to date);
- On completing these additional 10 sessions we will again be required to write back to the GP which will likely take a week;
- The fourth review may then be conducted by your GP who may choose to refer up to the limit of 40 sessions in a 12 month period (Maximum of 40 sessions to date)
- There is a limit of 40 sessions under EDP plans in any one 12 month period.
- Regardless of the sessions used you will need to go back to the GP on the anniversary of the original plan as no sessions can be rebated beyond the anniversary date without a completely new plan.
- If you have also been treated under either the Better Access or Chronic Disease Management Plans, then those sessions also count towards the EDP annual limits.
- If you see one psychologist for a couple of sessions then decide you want to see someone else you can, but your referral limits and 12 month limits don't reset.
See the following websites for more details:
1. https://www.servicesaustralia.gov.au/education-guide-eating-disorder-treatment-and-management-plans
2. http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=MN.16.1
Chronic Disease Management / Team Care Arrangement

This type of referral is unusual. We often see the forms for a CDM filled out by a GP by accident than them actually being used intentionally. These referrals entitle you to up to 5 rebated sessions in any calendar year. Rebates will be $56.00. Apart from the general rules above, the EDP rules also include:
- This type of referral is specifically intended to only be available to sufferers of a chronic condition requiring a multi-disciplinary approach. Your GP coordinates the care and is responsible for deciding if you meet the criteria set by Medicare.
- The patient must see the named psychologist on the referral, if you book in to see someone else you will need a new referral;
- The referral can't be for more than 5 psychological sessions but this might be reduced if there are other professions like OTs or speech pathologists sharing these 5 sessions. We will need the referral letter but you may also be given a multi page table format plan which is optional but recommended.
- Once we complete the first session your psychologist will need to write a report back to the GP;
- Once we complete the last session your psychologist needs to write a report back to the GP
- There is a limit of 5 sessions under CDM plans in any calendar year.
- If you are subsequently treated under an Eating Disorder Plan then then CDM sessions count towards the EDP annual limits.
- If you see one psychologist for a couple of sessions then decide you want to see someone else you can, but your referral limits and annual limits don't reset.
- You do not need to go back to your GP on Jan 1, used sessions roll over.
See the the following websites for more details:
1. https://www.servicesaustralia.gov.au/chronic-disease-gp-management-plans-and-team-care-arrangements
2. http://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=10968&qt=item&criteria=10968
NDIS Referrals
NDIS don't fund mental health treatment by default as they see the health system as being the most appropriate funding agency for clinical treatments in most cases.

However, if you have a long standing or permanent disability, whereby poor mental health is diminishing your ability to function independently, then non-clinical interventions may be funded for a range of activities such as:
- coaching you to help you improve your motivation, focus, knowledge and skills, resilience and decision-making so you can be more independent with day-to-day activities
- assistance to help you work with broader mental health, health system and other services by ensuring the supports you receive outside of the NDIS are responsive to your needs and helping you achieve your recovery goals
- support you to connect positively with family, friends and others.
See these websites for more information:

https://ourguidelines.ndis.gov.au/would-we-fund-it/improved-health-and-wellbeing/mental-health-supports
Self managedPlan ManagedAgency Managed
Self Managed NDIS

We are very happy to support self managed NDIS. We will work with you to track what you choose as your budget for psychology and put in place the necessary service agreements and setup your invoicing to minimise the burden on claiming back from NDIS. There may be out of pocket expenses depending on which psychologist you see as there may be a difference between their usual rates and the NDIS recommended rate.

You will need to upload our receipts to the myplace NDIS portal to receive NDIS payments back to cover some or all of the cost of your appointments.

See these websites for more information:

https://www.ndis.gov.au/participants/using-your-plan/self-management
Plan Managed NDIS

Not all of our psychologists will accept plan managed NDIS, but for those who do, we are very happy to work with your Plan Manager and bill them instead of you. There will not be any out of pocket expenses for you unless your NDIS Plan is not active, because, for example, it is under review or you run out of allocated budget. If this happens, then we will ask you to pay for sessions directly.

See these websites for more information:

https://www.ndis.gov.au/participants/creating-your-plan/ways-manage-your-funding/plan-management
Agency Managed NDIS

We are not registered for and will not register with NDIA to provide agency managed services. This is because it imposes an unmanageable administrative burden and risk on us. For instance if we don't advise NDIA before your appointment that an appointment has been scheduled then we will never be reimbursed for delivering that service. If NDIA reconsider their requirements then we will consider providing services under Agency management.
NDIS Number
Representative's Name

First NameLast Name
Representative's Email
example@example.com
Private Health Fund Rebates
We don't have the facility to process private health fund rebates on your behalf. Most funds use fairly consistent item numbers or do not require any specific formatting on their invoices. The following funds do.
BUPAHBFHCFOther
HCF currently requires that you extinguish all possible claiming under Medicare and have your psychologist declare as much before they will accept claims for psychology.

Rows	OK
Wise Institute is not a bulk billing service, that is we are not a free service, you will have out of pocket costs to receive help with us;
If the "patient" referred under Medicare is not present then rebates will not be claimable;
Cancellation fees are not covered under Medicare so you will be liable if you don't give us 24 business hours notice for appointments and this will not be claimable;
There are a complex set of rules that will see you going back to your GP regularly. GP's are bound by limits about how quickly they are able to complete re-referrals and they depend on our progress reports before authorising further sessions. In combination that may means that Medicare paperwork may not be in place at the time of all scheduled appointments;
We can't back date. That means that only appointments covered by a referral will be rebated;
We will do everything reasonably possible to try to help guide you through this complex system, including putting remaining session limits on every invoice and emailing you after your last authorised session, however if we fail to do so we are not responsible and do not indemnify you if you are unable to receive a rebate from Medicare.

Availability
At the moment we have limited availability for out of school times.
What days and times WILL NEVER work for you and we should avoid even offering if they become available?*
Example: Mon (am), Tues (pm), Wed (all day)
In person (Crows Nest)via Telehealth
Our Intake team will endeavour to contact you within two business days via phone or email. If they have a suitable appointment to offer they will contact you via phone, if there is a wait for an appointment or if other services are better suited to your needs, they will typically touch base by email. At any time they can be contacted on 02 9906 5198 (Mon - Fri, 9 - 5pm) or Intake@wiseinstitute.com.au Please let us know the specific times and days over the coming week when you are able to receive a call from our Intake team. *
Example: Mon 1/8 : 10am, 11am, 1pm or 3:30pm; Tues 2/8: anytime other than 2pm
Phone onlyEmail onlyText message onlyEqually quick to respond via Email, Phone or Text
Visitor information
Should be Empty:

Thanks for your enquiry!

Appointment Request

Your Details

Your Current Partner's Details

Child's details

Referral Details

Medicare Referrals

Better Access / GP Mental Health Care Plans

Eating Disorder Plans

Chronic Disease Management / Team Care Arrangement

NDIS Referrals

Self Managed NDIS

Plan Managed NDIS

Agency Managed NDIS

Private Health Fund Rebates

Current Situation

Therapeutic relationship

Therapeutic relationship

Risk factors

Legal matters

Legal Matters (WorkCover, SIRA or CTP)

Consent to services in cases of separated families

Purpose

Agreement

Availability