Customer Registration
Full Name as per the Medicare Card
*
Please enter both your first name and last name
Date of Birth
*
-
Day
-
Month
Year
Date Picker Icon
Gender
*
Male
Female
Non binary
Medicare Card/NDIS Number
*
Please enter Medicare Card/NDIS Number Ex: 3501 80315 1
Medicare Card Reference Number
What's the number to the left of your name on the Medicare card?
*
Medicare Card Expiry Details
*
Mobile Primary
*
Please enter your mobile number starting with 04
Secondary Number
*
Please enter a secondary phone number
Email
*
Address
*
Street Address
Street Address Line 2
Suburb
State
Postal Code
State
*
Next of Kin Name
Next of Kin Phone
Case Worker/Representative
How did you find us?
Youtube
Twitter
GP
Private Psychologist
Google Search
Public mental health service/Hospitals
NGOs
Other [Please state]
What devices you have access to?
Laptop
Desktop
Mobile Phone
Tablet
Other [Please state]
What device you most likely to access our service from?
Laptop
Desktop
Mobile Phone
Tablet
Other [Please state]
Other services of interest
Psychology
Other [Please state]
Can we have your consent to contact you regarding other services that you have selected above?
Yes
No
Do you have an NDIS package?
Yes
No
Have you seen another psychiatrist in the past 12 months?
Yes
No
Have you seen another psychologist or counsellor, this year, using a mental health care plan?
Yes
No
Do you want to be added to the late cancellation list for your clinician?
Yes
No
Can we get your consent to check your consultation history with Medicare? We may require this in order to check your entitlement for services provided
*
Yes
No
If you are wanting an ADHD assessment; does your referral clearly state that you are needing an ADHD assessment?
Yes
No
Please choose a date and time you will be available within the next two days to onboard with us via a Zoom call. *Details to be sent later
Submit
For office use only
Clinicians
Clinician1
Clinician2
Clinician3
Clinician4
Clinician Name
Harsh Chalana
Ileana Hatton
Jawad Adil
Joseph Kekulawala
Sukumar Rajendran
Zorica Gruneska
Harsh Chalana
Ileana Hatton
Jawad Adil
Joseph Kekulawala
Sukumar Rajendran
Zorica Gruneska
Harsh Chalana
Ileana Hatton
Jawad Adil
Joseph Kekulawala
Sukumar Rajendran
Zorica Gruneska
Harsh Chalana
Ileana Hatton
Jawad Adil
Joseph Kekulawala
Sukumar Rajendran
Zorica Gruneska
Billing Method
Clinician1
Clinician2
Clinician3
Clinician4
Billing Method
Bulk Bill
Gap Charge
Bulk Bill
Gap Charge
Bulk Bill
Gap Charge
Bulk Bill
Gap Charge
GP Provider Number
GP Name
GP Clinic
Clinic Name
Address
Fax Number
Email
GP Clinic
Current GP
Client Status
Inactive - Joseph
Inactive - Shalinda
Inactive - Sowmya
Inactive - Zorica
Inactive - Sandy
Inactive - Andrew
Inactive - Ileana
Inactive - Tim
Inactive - Adil
Inactive - Harsh
Inactive - Sukumar
Blacklisted
Rural/Metro
Rural
Metro
Have you informed the client about our Bulk bill clinical psychology service?
Yes
No
Informed client of clinicians no shows & late cancellation policies
Yes
No
Notes
Should be Empty: