CLIENT INTAKE & CONSENT FORM

for Koira Psychology and LifeGuide

Thank you in advance for completing this form.

Please complete questions with a red * . All other questions are optional.

General Information

Your first name *

Your family name *

Preferred first name

Your date of birth *

Gender identity

Your email address *

Mobile phone *

Home phone

Home Address

Please provide your home address details. *

Street address *

City

State *

Postcode *

Emergency Contact Information

Name of emergency contact

Emergency contact phone number

Work Information

Occupation

Which therapy service do you require?

Type of therapy service required *

Briefly describe your reasons for seeking psychology therapy.

Funding Preference

My NDIS is

My NDIS account number

My Work Cover reference number

My DVA card number

Mental Health Care Plan

Claimant Medicare Card Number

Claimant's Individual Reference Number

Claimant Medicare Card Expiry Date

Child's Medicare Card Number

Child's Medicare Individual Reference Number

Child's Medicare Card Expiry Date

Do you have a referral? *

YesNoHave made a GP/Psychiatrist appointment to get oneDon't need one-I'm self-referred and paying privately

If known, how many sessions are available on your current health care plan?

If you are using Medicare Rebate & have not provided your current plan to us, please upload here:

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You need a referral to be eligible for Medicare Rebate. Not having a referral may also impact your ability to claim for inpatient services from both Medicare and Private Health Insurers.

Communication

I will receive appointment reminders via *

SMS/Text MessagesEmail

Referral Source

How did you find out about us? *

Privacy and Confidentiality

In order to provide therapeutic psychology services, Koira Psychology will collect and record personal information relevant to your situation.

Purpose of collecting and holding information

Any personal information gathered as part of your assessment and treatment process will be kept securely and, in the interests of your privacy, used only by your psychologist and the authorised personnel of the practice (as necessary). Your personal information is retained in order to document what happens during sessions, assisting your psychologist to provide a relevant and informed service to you.

Access to client information

You are entitled to access your personal information kept on file, unless relevant legislation states otherwise. If you require access to your information please discuss this with your psychologist.

Disclosure of personal information

Personal information gathered by your psychologist during the provision of services is considered confidential and will not be disclosed to another party except when:

your prior approval has been obtained to:
provide a written report to another professional or agency. eg. a Doctor or Psychiatrist
discuss your care with another person, eg. a Legal Guardian, or Health Care Provider; or
it is subpoenaed by a court; or
failure to disclose the information would in the reasonable belief of your psychologist place you or another person at serious risk of harm; or
disclosure is otherwise required by law.

The Privacy Act

In March 2014, the Australian Privacy Principles (APPs) replaced the National Privacy Principles and Information Privacy Principles. The Privacy Act 1988 (Privacy Act) is an Australian law which regulates the handling of personal information about individuals. This includes the collection, use, storage and disclosure of personal information, and access to and correction of that information. The Privacy Act includes 13 Australian privacy Principles that apply to the handling of personal information. Click here for Privacy fact sheet 17 (Australian Privacy Principles) http://www.oaic.gov.au/privacy/privacy-act/the-privacy-act

Confidentiality

Will the things I discuss in therapy be kept private?

Confidentiality is a respected part of psychology’s code of ethics. Psychologists at Koira understand that for people to feel comfortable talking about private and revealing information, they need a safe place to talk about anything they’d like, without fear of that information leaving the room. Psychologists follow strict guidelines for professional conduct and confidentiality, and information will remain confidential unless you give your permission to release it. For example, you may wish your psychologist to discuss your care with your other health care professionals to coordinate your care. However, there are some exceptions…

When can a psychologist share my private information without my consent?

There are times when there are exceptions to confidentiality. For example, this may occur to protect you or the public from serious harm (i.e., plans to attempt suicide, plans to hurt others, child abuse). Other times may be if your psychologist is ordered to release information by the court. In addition, your psychologist will be required to write a report back to your referring GP if you are utilising a Mental Health Plan under the Medicare Rebate system. However, if you are self-referred, reports are not sent to your GP. You will receive Koira's Privacy Policy by email, which covers this information and discusses how your personal information will be handled.

If I access EAP, will my employer know I saw a psychologist and what will they know?

Koira Psychology do not give information to Employers about who has utilised services, or the information that is discussed within your sessions. You will usually have a number of sessions that has been approved by your employer – identified by number of sessions per employee. Your organisation is billed with hours that you have utilised. If you feel you need support, please discuss with your HR Department how you can access our Employment Assistance Program.

Consent

I confirm my consent to Koira Psychology for obtaining my information for administrative and therapeutic purposes. *

I confirm my consent to engage with psychology services with the psychologists at Koira Psychology. *

I understand that it is my right to withdraw services at any time. *

I confirm that above information I have provided is true, complete and accurate. *

Signature *

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Date *