Customer Registration
First Name
*
as per the Medicare Card
Last Name
*
as per the Medicare Card
Street Address (without Suburb,State or Postal Code)
*
*please type only the street address without the suburb
Suburb
*
State
*
Please Select
QLD
NSW
VIC
ACT
TAS
WA
SA
NT
Postal Code
*
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
*
Next of Kin Name
*
Next of Kin Phone
*
Case Worker/Representative
Please select a date and time within the next 10 days for a quick 5-minute onboarding call with our support coordinator via Zoom/Google Meet.
How did you find us?
Youtube
Twitter
GP
Private Psychologist
Google Search
Public mental health service/Hospitals
NGOs
Other [Please state]
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
For Psychiatry Clients
Have you seen another psychiatrist in the past 12 months?
Yes
No
Not Relevant
If you are wanting an ADHD assessment; does your referral clearly state that you are needing an ADHD assessment?
Yes
No
Not Relevant
For Psychology Clients
Have you seen another psychologist or counsellor, this year, using a mental health care plan?
Yes
No
Not Relevant
Submit
For office use only
File Name Generator Unique ID
GP & GP Clinic Details
GP Name
*
GP Provider Number
*
GP Clinic Name
*
GP Clinic Address
*
GP Clinic Fax Number
*
GP Clinic Email
Epsychiatry Clinician Details
Clinician Name
Please Select
Harsh Chalana
Jawad Adil
Joseph Kekulawala
Elizabeth Fyson
Steven Sin
Zorica Gruneska
Ileana Hatton
If the client has changed the GP
Please add new GP's name, GP clinic name and the address to the New GP Details below
New GP Details
Notes
Client Status
Active
Inactive
Blocked
Should be Empty: