Counselling Assistance Application Form

COUNSELLING SUBSIDY APPLICATION FORM
CFT provides financial assistance to members to undergo counselling with a registered Psychologist.

Process:

1. Complete this online form;

2. Attach any invoices for reimbursement;

3. You only need to fill in this form the first time you claim. In future just email your invoices to general@cftas.org.au.

4. CFT will endeavour to process your application within 5-7 days (subject to staff availability).
Name of Person undergoing counselling*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Post Code
Email*

Confirmation Emailexample@example.com
Mobile Number
Relationship to person with CF*
Details of person completing this form (if different from above)

Name

Street Address Line 2

Relationship

Mobile Number
Counselling Details
Under the Federal Government's Better Access to Mental Health program you are entitled to Medicare rebates for up to 20 sessions per calendar year with a registered psychologist or counsellor. CFT will fund the gap between this rebate and the fee charged by your provider. The gap can be up to $70, but this will vary depending on what your counsellor charges. To receive the Medicare rebate you need to get your GP to write a referral and a Mental Health Care Plan. CFT will only fund the full cost of counselling sessions if you have used all the available 20 sessions in a calendar year. Do you understand this? *
Name of counsellor or psychologist you will be seeing*
To access this subsidy you need to pay for your appointment, and then provide a copy of your receipt showing the fee and the Medicare rebate. CFT will then reimburse the gap fee to the bank account listed below.
BSB*
Account Number*
Bank account holder
Name
If you have an account to be reimbursed to you, please upload it here. Note: It needs to be an invoice from the Psychology Practice showing the fee and the Medicare rebate received.

Browse Files

Cancelof
DECLARATION

I declare that all information I have provided to Cystic Fibrosis Tasmania is true and accurate. I understand if it is found that I have knowingly provided false or inaccurate information I may no longer be eligible to be a member, or receive any or all of the services and benefits provided by Cystic Fibrosis Tasmania.
E-Signature Name*
Date*

DayMonthYear
Date
Should be Empty:

COUNSELLING SUBSIDY APPLICATION FORM

Counselling Details