Service Request

Service Request
This form is to be completed by the client, guardian or related third party of the client, such as an insurance agency. Please read carefully before completing to avoid delays in your request. If you are a related third party, ensure you have an up to date consent form completed by the client before proceeding as you will be required to provide this document for Strategic Psychology to consider your request.
If you are seeking the release of a clinical file from Strategic Psychology, please follow this link: https://form.jotform.com/strategicpsych/clinical-notes-request.

We understand that you are looking for a report, support letter or third party form to be completed by Strategic Psychology. In order to assess whether we are able to meet your needs, we first require some information from you. Kindly take the time to answer the following questions below to assist us with understanding your request.

Please note that after receipt of your Service Request, the following will occur:

1). We will review your request and if required, seek further clarification from you. There are instances where our psychologists will not be able to complete your request - you will be advised if this is the case.
2). If our psychologist can complete your Service Request, you will be provided with an invoice for your payment.
3). Upon receiving payment, we will complete your request within 20 business days and release the request accordingly.

If you are seeking reimbursement for your payment from a third party, please make arrangements with them directly.
I am completing this form as a:*

clientguardianthird party (e.g., insurer, legal representative, rehab provider)
Client Details

(This section refers to the individual attending appointments with Strategic Psychology)
First name*
Surname*
Date of birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

SuburbState

Postal Code
Phone number*
Mobile or landline with area code
Email*
Guardian Details
First name*
Surname*
Date of birth*

DayMonthYear
Guardian address*

Same as above clientDifferent to above client
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number*
Mobile or landline with area code
Email*
What is your relationship to the client?*
Third Party Details
First name*
Surname*
Position / role*
Organisation*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number*
Mobile or landline with area code
Email*
Request Details
Treating psychologist name
Reason for request*
How would you describe your request?*

ReportLetterThird party form to be completed (e.g. - Centrelink Form, Comcare Form)
Upload your third party form

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List of Questions
Please complete the following carefully as the list of questions you provide below will form the basis of your report or letter. If you do not provide a list of clear questions, we will need to seek clarity from you and your Service Request will be significantly delayed. See below examples to assist you in considering the questions you would like answered for this specific request.

Example Questions:

1). How many times have you seen Brad Jones?
2). Does Brad Jones meet the criteria for a mental health diagnosis?
3). How long does Brad Jones report he has been unable to work/attend school for
4). What symptoms does Brad Jones report experiencing and how are they affecting his capacity to attend work?
5). What is the prognosis for Brad Jones with respect to managing his mental health difficulties more effectively?
6). What type of therapy and frequency of sessions have you been providing to Brad Jones?
7). How would you describe Brad Jones' engagement in therapy and capacity to practice strategies covered in sessions?
8). Do you have any recommendations that Brad Jones' workplace/school could consider in supporting him?
Provide a list of questions you would like answered by your psychologist or upload them in next field. *
1.
2.
3.
4.
5. 
6.
7.You can list as many questions as you like
Upload schedule of questions

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Any relevant history for your psychologist to consider (type below or upload in the next item)
Upload relevant history

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Who would you like to have the service request released to?
As the client, I would like my service request released to:*

Myself - Using my email address provided aboveA third Party - Using the details and email address provided below
As the guardian, I would like the service request released to:*

Myself - Using my email address provided aboveA third Party - Using the details and email address provided below
As a third party, I would like the service request released to:*

Myself - Using my email address provided aboveA third Party - Using the details and email address provided below
Organisation*
Contact Person*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
Phone number*
Mobile or landline with area code
Upload client consent form

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Authority and Consent

Please acknowledge you have read and agreed to the statements below by ticking the boxes and signing your name.
I understand there will be an up front fee for this Service Request.*

Yes I understand
I understand that the treating psychologist may not be able to complete this Service Request in the preferred timeframe due to other clinical demands.*

Yes I understand
I understand that after making payment for this Service Request, it can take up to 20 business days to be completed.*

Yes I understand
As the client, I authorise and consent for Strategic Psychology to complete this request and share information relating to me with the above mentioned parties.*

Yes
As a guardian of the client, I authorise and consent for Strategic Psychology to complete this request and share information relating to the client with the above mentioned authorised parties.*

Yes
As a third party to the client, I have attached the clients consent form for Strategic Psychology to complete this request. The consent form authorises Strategic Psychology to share information relating to the client with the above mentioned parties.*

Yes
First name
Surname
Signature*

Clear
For the purposes of signing this authority and consent form, this electronic signature shall be deemed the same as an authentic signature*

Yes, I agree
Date*

DayMonthYear
Date for file

YearMonthDay
Email for auto-reply
example@example.com
Should be Empty:

Service Request

Client Details

Guardian Details

Third Party Details

Request Details

List of Questions

Who would you like to have the service request released to?

Authority and Consent