Home
Make An Appointment
Contact Us
Contact Us
Our Hub
Our Safety
Join Us
Priority Referral Form
Our League
Our Services
Our Services
Children
Youths
Adults & Couples
Families
Our Fees
Telehealth
Registration Form
Privacy and Consent Form
COVID-19 Resources
COVID Safety
Our Blog
Registration Form | NALA
16966
page-template-default,page,page-id-16966,ajax_fade,page_not_loaded,,vertical_menu_enabled, vertical_menu_transparency vertical_menu_transparency_on,qode-title-hidden,side_area_uncovered_from_content,qode-child-theme-ver-1.0.0,qode-theme-ver-16.8,qode-theme-bridge,disabled_footer_bottom,qode_header_in_grid,wpb-js-composer js-comp-ver-6.5.0,vc_responsive
Where Courageous Change Happens.
Online Registration Form
Please enable JavaScript in your browser to complete this form.
Clients Details
Client Name
*
First
Last
D.O.B
*
Phone
*
Gender
Other
Non-binary
Female
Male
Preferred Pronouns
e.g he/him, she/her, they/them
Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Email
*
Medicare No.
*
IRN
*
Exp
*
Claimant Details (Caregivers details for under 18 y/o clients)
Name
First
Last
D.O.B
Medicare No.
IRN
Exp
Emergency Contact Details
Name
*
Relationship to client
*
Phone
*
Email
*
Payment Details
Credit Card details for payment - It may be of help to both client and our Nala hub to have credit card details on file in case you need to make a payment without being present. There is an added surcharge for online payments, charged by our practice software.
Name On Card
*
Credit Card Number
*
Exp (MM/YY)
*
CVC
*
Bank Details
Bank Details
My bank details are already registered with Medicare (don’t complete if registered with Medicare)
Account Name
BSB
Account Number
Client Agreement
Consultation Fees
The current fee per standard consultation is $200 with a registered psychologist (a Medicare rebate of $87.45 may be available on these appointments) and $240 with a clinical psychologist (a Medicare rebate of $128.40 may be available on these appointments). The fee for the initial consultation is $245 with a registered psychologist and $285 with a clinical psychologist. Please contact the clinic for couples/family therapy fees, NDIS consultation fees, and provisional psychologist fees. Appointments outside of business hours incur a $25 surcharge (this includes appointments from 5pm onwards Monday-Friday, and Saturday appointments). Consultations are 50 minutes long. Nala hub charges below the Australian Psychological Society’s recommended fee of $260.00 for a standard consultation. Payment will be requested at the time of your consultation. A rebate may be available from Medicare if you have a valid GP Mental Health Care Plan. If you do not have a GP Mental Health Care Plan, your private health fund may cover part of the fee.
Cancellations
We understand that there may be times that you will need to cancel or change your appointment. We will do our best to reschedule or swap an appointment time however this may be difficult at late notice.
Cancellations made after 11am of the previous business day will incur a full consultation fee.
Confidentiality
Your confidentiality is protected except in certain circumstances including where we are mandated to report. These circumstances include where it is deemed that you and/or another person is in danger and when we are legally obliged through a court summons to provide relevant notes. We will also provide general information about your assessment to the referring health professional, unless you advise otherwise.
Agreement
*
I have read and agree to the above terms and conditions of this service
Permission to Share Information
Please list the names and contact details of any professionals who you would like us to have contact with. You are able to withdraw consent at any time by speaking with your psychologist.
GP Name
GP Phone Number
Psychiatrist
Psychiatrist Phone Number
School Counsellor
School Counsellor Phone Number
Other
Phone Number
Electronic Submission
Signature
*
By checking this box I acknowledge that this qualifies as an electronic signature and that all information provided is accurate.
Email
Submit