Privacy and Consent Form
Priority Referral Form
Adults & Couples
Registration Form | NALA
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Where Courageous Change Happens.
Online Registration Form
Address Line 1
Address Line 2
State / Province / Region
Claimant Details (Caregivers details for under 18 y/o clients)
Emergency Contact Details
Relationship to client
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
My bank details are already registered with Medicare (don’t complete if registered with Medicare)
The current fee per standard consultation is $190 with a psychologist and $230 with a clinical psychologist. The fee for the initial consultation is $235 with a psychologist and $275 with a clinical psychologist. Consultations are 50 minutes long. Nala hub charges below the Australian Psychological Society’s recommended fee of $251.00 for a standard consultation. Payment will be requested at the time of your consultation. Please pay by EFTPOS or cash. A rebate may be available from Medicare, under a 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.
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.
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.
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 Phone Number
Psychiatrist Phone Number
School Counsellor Phone Number
By checking this box I acknowledge that this qualifies as an electronic signature and that all information provided is accurate.