Psychology Telehealth e-Form (initial)

Initial (tele) Consultation

Please fill out the following Telehealth e-Form with your details and click the submit button at the end. We will contact you after we receive your completed form.

(Please fill out all the fields) (Form: psycinitial)

Child's (Patient) Details

Date of Birth

Address


Parent 1 Details

Date of Birth

Parent 2 Details


Medicare Card Details


Clarification about telehealth services (consent required)

We want to make sure you are aware that:

  • A video/phone consultation will not be exactly the same, and may not be as complete, as a face-to-face service.
  • There could be some technical problems that affect the quality of a video visit. Please confirm you understand the limitations of a health service provided online and are happy to proceed.
  • If the teleconference does not achieve everything that is needed, you will be given a choice about what to do next. This could include a follow up face-to-face visit, or a second video/phone visit.
  • You can change your mind and stop using teleconference consultations at any time. This will not make any difference to your right to ask for and receive health care.
  • It is a requirement that both parents/guardians (where applicable) consent for telehealth services to be provided by a practitioner (psychologist). If for any reason it is not possible to obtain a consent as required please let us know before your scheduled appointment.
  • Please upload any supportive/related document such as a referral, clinical history, previous reports/assesments, etc you might have and would be helpful as it is clinically important for our practitioners to have the information they need.
  • Telehealth consultations are eligible for Medicare rebate equal to MBS 91167 ($128.40) if you have a Mental Health Care Plan (MHCP) or Enhanced Primary Care (EPC) or a referral from your GP. Psychology sessions for counselling are billed at a cost of $250 per 50-minute session.

Debit account & credit card payment authorization

By completing this part you hereby authorize Brighton Health Clinic for Kids to debit your bank account or credit card shared below, for each session on the day of consultation. This is permission for the amount to be charged as per our fees described above. Any additional costs for extended sessions or further assessments cannot be charged without confirmation from the client. This authorization does not provide authorization for any additional unrelated debits or credits to your account.

We take automatic payment on the day of consultation and a receipt is issued via email. All credit card payments will incur a surcharge of 1.010% during processing. Kindly note that declined cards may result in an additional processing fee as it will go through an additional process when the attempted card is charged again. You authorize the above named business to charge your bank account or credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the services described above, for the session cost only. You certify and confirm that you are an authorized user of this bank account or credit card.


** Supplementary Consent Information - please click here to read (pdf file)

Both parents consent to all the above: Yes, No

Payment Details

Credit Card Type
Card Number:

Please upload referral or related documents