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
DOB of CF Patient

MonthDayYear
Date
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 10 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 $100, 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 sessions under your mental health care plan. Assistance under this policy is limited to $1000 per year. If you do not get a Mental Health Care Plan, dependent on what your psychologist charges, our support will only fund around 4 visits. If your private health fund covers psychologist visits please contact us to discuss how we can assist you. 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