Telehealth New Patient Registration Form

New Patient Request (Telehealth)

Please fill out the form below
Child's Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Child's School and Grade
Parent's Name
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?
For separated families: Do you have sole or shared decision making regarding your child?*

Sole*Shared**Not separated
*If you have selected sole decision making, please provide copies of the relevant court documents.

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**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
Date
Your Name

First NameMiddle NameLast Name
Information Statement

Fees:

· $245 for Jodie Wassner or $225 for Lize Booy, 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 ($245/$225), 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).

· Late collection of children from appointments will incur a fee.

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

· Fees outstanding for more than 7 days 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.

Appointment Times:

·      Please note that appointments out of school hours are in demand and may not always be available.

·      It is suggested that multiple appointments are booked in advance for patients requiring regular appointments.

·      For new patients, there may be a wait of a few weeks before regular times can be established.

·      Patients are encouraged to go on the cancellation list as these often become available.

·      If the patient requires more urgent attention, referral to another psychologist can be arranged.

When to join your child’s session with the psychologist:

The psychologist tends to spend most of the appointment alone with the young person. This is essential for building trust and acceptance, which is the most reliable factor in determining success of therapy.

Parental input is also an important part of the process, both in terms of assessing what is happening, as well as providing families with tools to take home. The psychologist has created procedures to balance parental input with the child’s needs.

At times, parents will be invited into the therapy room towards the last 10-15 minutes of the session to hear about strategies discussed and to create home plans. This does not happen during every session, but it is important to make yourself available in case the young person requests your presence.
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New Patient Request (Telehealth)