NDIS Client Intake - Melbourne Counselling

Full Name*

First NameLast Name
Email*
example@example.com
Mobile*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

SuburbState

Post Code

NDIS Client#*
Client Birthdate*

DayMonthYear
Date
Client Age
NDIS Plan Manager Company Name (for Billing Purposes)*
NDIS Plan Manager Phone#*
NDIS Plan Manager Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of Support Coordinator or LAC
Phone# of Support Coordinator or LAC

Confidentiality and Record Keeping Policy
At Melbourne Counselling we take confidentiality and privacy very seriously. Having a high degree of confidentiality is an essential part of creating a safe space for therapeutic work. We aim to offer a caring therapeutic environment where you feel free to openly explore and share parts of yourself which you may not otherwise choose to share with others. Client confidentiality is kept in accordance with the ethical guidelines of the Australian Counselling Association (ACA). Please be aware that your personal information and anything you share during the sessions will be kept confidential, except in the following circumstances:

(1) When failure to disclose the information would place you or another person at risk of harm; or

(2) It is subpoenaed by a court; or

(3) Your prior approval has been obtained to:

(a) provide a written report to another professional or agency—e.g. to a lawyer; or

(b) Discuss the material with another person—e.g. an employer or agency.

(4) As part of the ongoing professional supervision that all registered counsellors are required to undertake, details of your case may be shared with a supervisor in a way that does not identify you directly. Individually identifying information is never disclosed in supervision, and any client information that may be shared during supervision is protected under a contract of confidentiality.

INFORMATION SECURITY AND ACCESS:

Your counsellor will take case notes either during and / or on completion of a counselling session or other communication with you. All notes taken in the course of your treatment and all communications relating to your treatment become a part of your client record. Your client record is stored electronically and is encrypted. You have a right to access your record at any point by making a request in writing. We are required to store your client record for 7 years after you cease engagement with your counsellor.
I have read, understand and agree to the Confidentiality and Record Keeping Policy*

Yes

Melbourne Counselling Attendance & Cancellation Policy
CONFIRMING APPOINTMENTS: We will endeavour to contact you via email to confirm appointments. However, it remains your responsibility to be aware of your scheduled appointments.

TIME AND PUNCTUALITY: A consultation will usually last 55mins. If you are late, your consultation will usually still finish at the scheduled time, to be fair to your counsellor and the patients with appointments after yours.

CANCELLATION POLICY: If you need to cancel or postpone an appointment we require at least 24 hours notice. Cancellations with less than 24 hours notice will incur a fee of $70 which is due on the day of your scheduled appointment. If you do not show up for a scheduled appointment, or give less than 8 hours notice, the full appointment fee will apply.
I have read, understand and agree to the Attendance & Cancellation Policy*

Yes

Counselling Payment Agreement for NDIS Clients
I, {fullName}, confirm that I'm a current participant in the National Disability Insurance Scheme (NDIS) and with respect to receiving counselling services from Melbourne Counselling I agree to:

1. Be responsible for ensuring that any sessions or support I receive from Melbourne Counselling fall within the guidelines of my NDIS Plan

2. Ensure there are sufficient funds in my NDIS Client budget to pay for the services requested

3. Inform Melbourne Counselling of any changes to my personal circumstances that may affect the delivery of services

4. Inform Melbourne Counselling of any changes to my personal contact details including my phone# or address, as well as to any change to my NDIS Plan Manager and their contact details

5. Communicate with Melbourne Counselling in a timely manner if I have any concerns about the Services being provided

6. Inform Melbourne Counselling immediately if my NDIS plan is suspended or replaced, or I stop being a qualified Participant in the NDIS.

7. I understand that if any of the Services I have booked with Melbourne Counselling are not able to be paid by the NDIS, I agree to pay for these services as a private client.
Signature*

Clear
Signed by: {fullName}
Date Signed

DayMonthYear
Date
Should be Empty:

Confidentiality and Record Keeping Policy

Melbourne Counselling Attendance & Cancellation Policy

Counselling Payment Agreement for NDIS Clients