OPEN MIND PSYCH Psychology Intake Form

OPEN MIND PSYCH

Intake and Informed Consent Form
Who is seeking counselling?*

MyselfMy ChildOther
Personal Information of Counselling Person
Name*

PrefixFirst NameLast Name
Date of Birth*

DayMonthYear
Gender*

MaleFemaleOther
School Name (If Applicable)
School Year (If Applicable)
Email*
example@example.com
Mobile
Mobile/Phone Number*

Area CodePhone Number
Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Emergency Contact
Name*

First NameLast Name
Email*
example@example.com
Mobile *
Mobile/Phone Number*

Area CodePhone Number

Your Information
Name*

First NameLast Name
Email*
example@example.com
Mobile
Mobile/Phone Number*

Area CodePhone Number
Is your address same with the counselling person?

YesNo
Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Relationship with the counseling person

ParentGrandparentCarerFriendOther

Psychological Service
As part of providing a service to you, Open Mind Psych will need to collect and record personal information that is relevant to your treatment. You do not have to give all your personal information, but if you don’t this may limit the services provided to you. Information is kept in order to record what happens during sessions, and helps the psychologist to provide relevant psychological services.

Access to Client Information
Request for access to client information: At any stage, you may access the material recorded in your file, subject to exceptions as stated in the Privacy Amendment Act 2000 (National Privacy Principal 6). This means that your request must be serious in nature, i.e. “the request must not be frivolous or vexatious.” Any request to access your information must be lodged with your psychologist, with an appointment made for clarification purposes at the cost of a standard consultation.

Confidentiality
All personal information gathered by the psychologist during the psychological service will remain confidential. Limitations to confidentiality are:

1) when disclosure is required by law or subpoenaed by a court

2) when failure to disclose information would place you or another person at serious and imminent risk

3) when your written consent has been obtained, and 4) provide a written report to
another professional or agency (e.g. a GP or a lawyer)

Fees
Fees are payable at the time of the consultation. Usual Medicare rebates apply for individuals on a valid Mental Health Care Plan. There are no Medicare rebates, or
TAC or WorkSafe reimbursements, for late cancellations or missed appointments. Couple sessions and reports are not Medicare rebated. Reports will attract GST.

Cancellation Policy
If for some reason you need to cancel or postpone your appointment, we require that you give us at least 24 hours’ notice, otherwise you will be charged your full session fee. This fee is strictly enforced.

Bulk-billing

Under exceptional circumstances, we will consider your request to be bulk-billed. By accepting these terms, you will be providing us authorization to submit a claim for the Medicare benefit on your behalf via Webclaim.

Direct Debit Authorisation for Payment & Cancellations
Your first invoice will prompt you to set up a Direct Debit Authorisation via GoCardless. Please ensure that you set this up to authorise your direct debit and/or to ensure that if you do not provide adequate notice, we are authorized to charge you the cancellation fee.

Consent for Recording Therapy Session Using AI

I understand and agree to the recording of my therapy session using Artificial Intelligence (AI) technology. The purpose of this recording is to assist in reviewing, analysing, and documenting the session for therapeutic purposes.

Purpose of Recording: I understand that the sessions will be recorded solely for clinical note-taking and therapeutic purposes. The recordings will aid in the formulation of treatment plans, assessment, and evaluation of progress. The AI program is designed to assist the therapist in providing more effective treatment and is not a replacement for human judgment or therapy.

Data Collection: I acknowledge that only essential personal and health information relevant to the therapy process will be collected during the sessions. This may include but is not limited to verbal communication, behavioral observations, and emotional expressions.

Privacy and Confidentiality: I understand that the information collected during the sessions will be handled with the utmost confidentiality and in compliance with international privacy regulations such as HIPAA and GDPR. My personal and health information will be securely stored and accessible only to authorised personnel involved in my treatment.

Withdrawal of Consent: I acknowledge that I have the right to withdraw my consent for the recording of sessions at any time, without affecting the quality or continuity of my therapy. I understand that upon withdrawal of consent, any existing recordings will be securely deleted, and no further recordings will be made.

Benefits and Risks: I understand that the use of AI-based software for session recording may enhance the quality of therapy by providing accurate and detailed clinical notes. However, I acknowledge that there may be potential risks, such as the possibility of technical errors or breaches of confidentiality, despite security measures in place.

I understand that not all sessions will be recorded, and will be at the discretion of the practitioner.

I hereby consent to the recording of our therapy session using AI technology and understand the purposes and implications of such recording.

Medicare Details (Enter N/A if you do not have a Medicare card)*

Medicare NumberReferenceExpiry
Do you have a concession card?*

Yes I have entered my details belowNo
Concession Card Details (Enter N/A if you do not have a Concession card)*

Card TypeCard NumberExpiry

Please upload your GP Referral (if applicable)

Cancelof
Please upload your TAC/NDIS/Work Cover approval letter (if applicable)

Cancelof
Please upload any relevant court orders (if applicable)

Cancelof

Signature*

Clear
Date*

DayMonthYear
Name of Patient/Guardian*

First NameLast Name
Should be Empty:

	Never	Sometimes	Often	Always
1. I found it hard to wind down
2. I was aware of dryness of my mouth
3. I couldn't seem to experience any positive feeling at all
4. I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion
5. I found it difficult to work up the initiate to do things
6. I tended to over-react to situations
7. I experienced trembling (eg, in the hands)
8. I felt that I was using a lot of nervous energy
9. I was worried about situations in which I might panic and make a fool of myself
10. I felt that I had nothing to look forward to
11. I found myself getting agitated
12. I found it difficult to relax
13. I felt down-hearted and blue
14. I was intolerant of anything that kept me from getting on with what I was doing
15. I felt I was close to panic
16. I was unable to become enthusiastic about anything
17. I felt I wasn't worth much as a person
18. I felt that I was rather touchy
19. I was aware of the action of my heart in the absence of physical exertion (eg, sense of heart rate increase, heart missing a beat)
20. I felt scared without any good reason
21. I felt that life was meaningless

OPEN MIND PSYCH

Personal Information of Counselling Person

Emergency Contact

Your Information

Presenting Problems