William Escobar Intake Form

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Mental Health Care PlanNDIS

NDIS Referral Form
Formal Diagnosis/es
Include all known medical and mental health diagnoses.
Presenting problem
Behaviours of Concern
Please specify all current medication
Are there Allied Health and Specialists involved in your care?
NDIS Goals
Permission is given for the psychologist to obtain and exchange appropriate written or verbal information with the following persons/agencies

NDIS Service Agreement
Participant's Name*

PrefixFirst NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Participant's NDIS number*
Phone Number*
Please enter a valid phone number.
Plan Start Date

DayMonthYear
Date
Plan End Date

DayMonthYear
Date
This Service Agreement is made for the purpose of providing supports under the clients NDIS plan.

A copy of the clients NDIS Plan is/is not attached to this Service Agreement. The parties agree that this Service Agreement is made in the context of the NDIS, which is a scheme that aims to:

Support the independence and social and economic client of people with disability; and enable people with a disability to exercise choice and control in the pursuit of their goals and the planning and delivery of their supports.
NDIS plan to be provided to Anima Hub.

3. Schedule of supports

Anima Hub agrees to provide the client Psychology services. The supports and their prices are set out in the attached Schedule of Supports. All prices are GST inclusive (if applicable) and include the cost of providing the supports. Additional expenses (i.e. things that are not included as part of a client NDIS supports) are the responsibility of the client / clients representative and are not included in the cost of the supports.

4. Anima Hub Responsibilities

Anima Hub agrees to:
- Review the provision of supports at least annually with the client;
- Once agreed, provide supports that meet the client's needs at the client's preferred times;
- Communicate openly and honestly in a timely manner;
- Treat the client with courtesy and respect;
- Consult the client on decisions about how supports are provided;
- Give the client information about managing any complaints or disagreements and details of Anima Hub's cancellation policy;
- Listen to the client’s feedback and resolve problems quickly;
- Give the client a minimum of 48 hours notice if Anima Hub has to change a scheduled appointment to provide supports;
- Give the client the required notice if Anima Hub needs to end this Service Agreement (see "Ending this Service Agreement" below for more information);
- Protect the client's privacy and confidential information;
- Provide supports in a manner consistent with all relevant laws, including the NDIS Act 2013 and Rules, and the Australian Consumer Law;
- Keep accurate records on the supports provided to the client; and
- Will issue invoices and statements of the supports delivered to the participant as per the NDIA Terms of Business for Registered Providers as requested
5. Responsibilities of the client / client representative

The client / client representative agrees to:
- Inform Anima Hub about how they wish the supports to be delivered to meet the client needs;
- Treat Anima Hub employees with courtesy and respect;
- Talk to Anima Hub if the client has any concerns about the supports being provided;
- Give Anima Hub the required notice if the client cannot make a scheduled appointment, noting that if the notice is not provided , a cancellation policy will apply;
- Give Anima Hub the required notice if the client needs to end this Service Agreement (see 'Ending this Service Agreement' below for more information); and
- Let Anima Hub know immediately if the client NDIS plan is suspended or replaced by a new NDIS plan, or the client stops being a participant in the NDIS.
6. Payments

Anima Hub will seek payment for their provision of supports after the supports have been delivered.
Please specify Funding type*

Self Managed - The client / client representative has chosen to self-manage the funding for NDIS supports provided under this Service Agreement. After providing those supports, Anima Hub will send the client / client representative an invoice for those supports for the client / client representative to pay. The client / client representative will pay the invoice by EFT within 7 days.Plan Managed - The client has nominated the Plan Management Provider to manage the funding for NDIS supports provided under this Service Agreement. After providing those supports, Anima Hub will claim payment for those supports from
Plan Manager Provider Name
Plan Manager Email Address
7. Changes to this Service Agreement

If changes to the supports or their delivery are required, the parties agree to discuss and review this Service Agreement. The parties agree that any changes to this Service Agreement will be in writing, signed and dated by the parties.

8 Ending this Service Agreement

Should either party wish to end this Service Agreement they must give 2 weeks notice. If either party seriously breaches this Service Agreement the requirement of notice will be waived.

9. Feedback, complaints and disputes

If the client wishes to give Anima Hub feedback or is not happy with the provision of supports and wishes to make a complaint, the participant can talk to Name on 0400 000 000 or email

If the client is not satisfied or does not want to talk to this person, at any time, they can make a complaint to the NDIS Commission. Complaints to the NDIS Commission can be lodged:
- online at www.ndiscommission.gov.au; or
- by phone on: 1800 035 544.
10. Goods and Services Tax (GST)

For the purposes of GST legislation, the Parties confirm that:
- a supply of supports under this Service Agreement is a supply of one or more of the reasonable and necessary supports specified in the statement included, under subsection 33(2) of the NDIS Act, in the client's NDIS Plan currently in effect under section 37 of the NDIS Act;
- the client's NDIS Plan is expected to remain in effect during the period the supports are provided; and
- the client / client representative will immediately notify the provider if the client's NDIS Plan is replaced by a new plan or the client stops being a participant in the NDIS.
11. Cancellation Policy

At Anima Hub we value consistent and high quality intervention. If you need to cancel an appointment it is recommended it occur before 48 hours before your appointment to avoid a cancellation fee, being 100% of the scheduled fee appointment. Where Anima Hub cancels a support due to operational reasons, the service will be rescheduled at no penalty to either party. Where multiple cancellations or no shows occur in a 12-month period, Anima Hub will initiate contact with the family and their support network to establish the supports we are providing are best suited to the family dynamics and the needs of the participant.
12. Contact Details*

As aboveNo
Client Representative Name*

First NameLast Name
Client Representative Email*
Client Representative Phone Number*
Practice can be contacted on:

Email: hello@animahub.au
13. Schedule of supports

I/we agree to pay for treatment/ therapy sessions provided by Anima Hub through claiming against the National Disability Insurance Scheme (NDIS) service plan. Working with the NDIS we have been allocated psychology funding for the service year.

The Provider agrees to provide the client Psychology services for the duration of the agreement at the scheduled rate as per NDIS guidelines, item number 15 054 0128 13.

These include:
- Psychological assessment and treatment
- Clinically relevant communications including phone calls/written programs/communication with other health professionals (any task that takes more than 6 minutes will be invoiced)
- Attendance at team meetings/case conferences
- Assessment and trial of equipment as required
- Any reports, forms or letters as required by the NDIS or requested by the client / client representative
- Cancellation charges for late notice or no show appointments
- Anima Hub reserves the right NOT to provide service or to cancel any future appointments for the client if you do not have sufficient funds in your plan or the plan expires. Any service fees not met by NDIS will be covered by your client / client representative.
Amount of Hours you wish to allocate to this Service Agreement*
14. Agreement Signatures

The parties understand and agree to the terms and conditions of this Service Agreement.
Client Representative Name

First NameLast Name
Signature

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Date

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Date
Upload NDIS Plan

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Consent to Exchange and Release Information
Participant's Name*

PrefixFirst NameMiddle NameLast Name
The organisation will comply with relevant privacy legislation and NDIS (provider registration and practice standards Rules 2018) in the standards set for dealing with personal information outlined in our policy, practice guidelines and procedures.

Client Representative/Referrer: Please discuss the following statement with Participants before proceeding.

Please note for participants under a Guardianship Order, consent in writing must be obtained prior to services.

The organisation will work closely with other agencies to coordinate the best support for you and your family. Your informed consent for the sharing of information will be sought and respected in all situations unless:
- We are obliged by law to disclose your information regardless of consent or otherwise.
- It is unsafe or impossible to gain consent or consent has been refused; and
- Without information being shared, it is anticipated a child, young person or adult will be at risk of serious harm, abuse or neglect, or pose a risk to their own or public health or safety.
- The organisation will only collect personal information, and details regarding my health, that is necessary for them to deliver a service to me. The organisation will take all necessary steps to protect my right to privacy and confidentiality when collecting my personal information.
- All information collected will be handled and maintained in a secure environment.
- I am aware that my personal information and details will be stored electronically.
- I will be consulted if the organisation needs to share my personal information, in order to provide me with the best possible care or to minimise or prevent risk to myself or others, including medical information such as confirmation of diagnosis reports, doctor’s orders.
- I have the right to request to see my health records and to request a correction if I believe the information is wrong. I am aware that social/behavioural/psychological reports/data or other research may be gathered by Anima Hub.
- I have identified below any other individuals/services which I give informed consent for the organisation to contact on my behalf. I am aware that data collected by the organisation may be used for the purpose of improvement in service delivery or reporting purposes, however personally identifying information will not be included in any reporting activities.
- I may cancel all or part of this agreement at any time, by advising the organisation of my decision via email to hello@animahub.au
- I will be offered a copy of my signed consent.
Consent*

I have read and understood the terms and conditions set out above. I consent to share information for Anima Hub to assist me with the handling and linkage of services to and from the parties as listed in this consent form. I understand should the need arise and changes need to be made to my information I can change / withdraw my consent at any given time, I will send my request in writing to hello@animahub.au
Signature*

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Date*

DayMonthYear
Date
Signed By:*

ParticipantClient Representative

Mental Health Care Plan Referral
Client's Name*

PrefixFirst NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Date
Sex*

MaleFemale
For Children and Adolescents (Parents/Guardian details)

First NameLast Name
School Name (If Applicable)
School Year (If Applicable)
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Occupation
Are you of Aboriginal or Torres Strait Islander origin?

NoYes, AboriginalYes, Torres Strait IslanderYes, both Aboriginal and Torres Strait Islander
Ethnicity
Referral Details
Referring Doctor's Name

First NameLast Name
Referral Date

DayMonthYear
Date
Medicare Card Details

Medicare NumberReference NumberExpiry Date
Name of Practice
Practice's Phone Number
Emergency Contact

As per guidelines when conducting Telehealth, two emergency contacts are required.
Name*

First NameLast Name
Email*
Phone Number*
Name*

First NameLast Name
Email*
Phone Number*

Online Telehealth Consent Form
This Online Telehealth Consent Form is required in addition to the ‘Consent Form’ and outlines the terms of online and phone therapy.

Telehealth services are not suitable for all clients, and this will be discussed with you by your psychologist. Alternatives to receiving online therapy services will be discussed if required and available.

Online Therapy Sessions

Once a telehealth session is scheduled, an email will be distributed to your email with instructions on how to connect to your session via the secure online platform. Clients are required to download and use the free Zoom app/software.

Zoom can be used with Windows, Mac, and on tablet and mobile devices. Your psychologist can help you with instructions for downloading Zoom to your device.

Recording of Telehealth Sessions

Telehealth sessions will not be recorded by your psychologist, and all clients are asked to respect the privacy of their psychologist by agreeing not to make recordings of therapy sessions and not to use materials from therapy sessions for purposes other than therapy (e.g., posting any portion of sessions on internet websites and/or social media is not permitted).

Procedures in Case of Technical Difficulties or Disruptions in Service

In the event of technical difficulties or disruptions, an attempt to resolve the difficulties will occur in the first instance, clients will be contacted by phone if reconnection is not possible within 5 minutes to discuss whether to continue or reschedule the telehealth session.

Privacy

While every effort will be made to keep all information confidential, the privacy of any form of communication via the internet is potentially vulnerable and limited by the security of the technology. Clients are responsible for understanding the potential risks of confidentiality being breached through unencrypted email, in transit by hackers or internet service providers, lack of password protection or leaving information on a public access computer.

Safeguards and Client Responsibilities

Clients are responsible for creating and using additional safeguards with devices used to access for our services, particularly when their devices are shared or may be accessed by others. Responsibilities includes creating complex passwords for devices, keeping all passwords secret, ensuring all email and online therapy sessions are exited properly and maintaining security of their wireless internet access points. For more information clients are encouraged to read cybersecurity resources provided by the Australian Cyber Security Centre.

Getting the most out of your Telehealth Service

Clients will need to have a secure WIFI or internet connection, a working webcam and audio on their device.

Please Note: Clients are responsible for any costs incurred during the telehealth session, including data usage and equipment or software.

Clients would benefit and as such are greatly encouraged from choosing an environment for their telehealth session where there is minimal noise interference, and where they are least likely to be overheard by others or interrupted.

Please Note: Misunderstandings may occur due to connection problems causing delays or less than optimal audio and image quality. Clients would benefit from approaching misunderstandings with patience and clarifying any potential misunderstandings with their psychologist.

Medicare Requirements

The client is referred by a GP (or Psychiatrist) with a valid and active mental health treatment plan and referral letter; and the client is not an admitted patient in hospital

At the advice of the APS, clients receiving telehealth services should provide the names of at least two local emergency contacts, before beginning their first online therapy session. This will allow the psychologist to make necessary arrangements in the event of an emergency.

For more information regarding telehealth services, clients are encouraged to read the Fact Sheet provided by the APS via this link.

By agreeing to participate in telehealth sessions, I agree to expressly release Anima Hub from any liability associated with unintended cyber security issues and/or difficulties with unsecured communication.
Informed Consent for Psychological Services
Nature and purpose of the Psychological Service

As part of providing a psychological service including assessments and counselling to you, Anima Hub will need to collect and record personal information pertaining to you. This information is a necessary part of the psychological assessment and treatment that is conducted.

Psychological therapy may vary and depend on the issues brought forward. Psychological therapy calls for a very active effort on the client behalf. For the therapy to be most successful, you (the client) will have to work on things we talk about both during our sessions and at home.

Initial sessions will involve an evaluation of your needs. By the end of the evaluation, the therapist will be able to offer you a treatment plan to follow. Should you have any questions during therapy feel free to discuss these. You (the client) can cease therapy with the therapist at any time. You may wish to pursue another treating practitioner; your therapist will make every endeavour to ensure this is facilitated.

Access to your information

As part of providing psychological services, relevant personal information to the current situation will be collected and recorded. The information will assist in providing an appropriate and thorough service. Information will be stored in a secure location for a minimum of 7 years, or if you (the client) are under the age of 18 at the time of treatment, until you are 25 years of age. You may access the information in your file on request, subject to the exceptions in the National Privacy Principles.

Confidentiality and Privacy

All personal information gathered by the psychologist during the provision of psychological service will remain confidential and secure except when:
1. It is subpoenaed by a court, or disclosure is required or authorised by law; or
2. Failure to disclose the information would place you or another person at risk of harm; or
3. Given your prior approval, or consent of a parent or guardian who is legally authorised to act on your behalf in order to provide a written report to another professional or agency, or discuss information with another person e.g., parent or employer; or
4. You would reasonably expect your personal information to be disclosed to another professional or agency and disclosure is directly related to the primary purpose for which it was collected such as to inform your GP of treatment and progress; or
5. Clinical consultation with another professional is required to provide better clinical services (identifying details will remain confidential).
If during the course of your work with Anima Hub, he becomes aware of risk to someone’s life, health, or wellbeing, he is required by policy of the state and federal governments to report the matter to the appropriate agencies.

Session Fees

My agreed fee is $240 for children and adolescents and $270 for adults per session (one hour duration) and is payable at the time of consultation.

Private Health Insurance

Some health insurance policies cover counselling depending on the policy. Please check with your insurance company as to what cover you are eligible.

Medicare Rebates

Under the Medicare Benefits Schedule (Better Access), Medicare rebates are available to clients with an assessed mental disorder. Medicare rebates are accessed with a Mental Health Treatment Plan and referral from a medical practitioner, psychiatrist, or paediatrician. The rebate is limited to 10 sessions per calendar year and only available with a valid referral. Please note the maximum number of sessions per referral is 6 and rebates will not be given beyond the number stated on the referral.

Cancellation Policy

If for some reason you need to cancel or postpone your appointment, please give at least 48 hour notice the day prior. Should notice be provided on the day of the appointment, the full fee will be charged. This includes for all No Shows to an appointment. This no show or late cancellation fee will need to be paid on or before your next visit. Please make every effort to notify the practitioner. To cancel or rearrange an appointment, please call Anima Hub on 0426 926 171.

Emergency

In case of emergency, please go to the emergency department of the nearest hospital. For further information refer to the website for your local health district. For out of hours phone support, you may find it helpful to call Lifeline on 13 11 14. Please refer to animahub.au for more crisis lines.
Consent
I, {clientsName} have read and understood the above consent form provided by Anima Hub and have had the opportunity to have any questions I may have about it answered. I agree with the psychological service provided and the associated fee I am required to pay.

Exchange of Information Consent

All personal information gathered during the provision of psychological services will remain confidential and secure except when:

1. Your prior approval has been obtained to:
1. Provide a written report to another professional or agency (e.g., a school, GP, solicitor, etc); or
2. Discuss the material with another person (e.g. a teacher, doctor, parent, etc); or
2. Failure to disclose the information would place you and/or another person at risk; or

3. It is subpoenaed by a Court In order to provide a comprehensive psychological service, it is sometimes necessary to exchange information about you with other people.

By signing this form, you give your psychologist permission to seek information about you, to release information about you, and/or to discuss your situation within the limits outlined below. The information exchanged assists your clinician to make a thorough assessment and treatment plan for you or may help other professionals provide services for you. You have a right to withdraw this consent at any time by telling your clinician or putting your request in writing.
Signature*

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What type of referral is this?

NDIS Referral Form

NDIS Service Agreement

Consent to Exchange and Release Information

Mental Health Care Plan Referral

Referral Details

Emergency Contact

History

Online Telehealth Consent Form

Informed Consent for Psychological Services

Consent