Registration Form | NALA

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Where Courageous Change Happens.

Online Registration Form

Clients Details

Client Name *

First

Last

D.O.B *

Phone *

Gender

What are they correct 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. *

10 Digit Number

IRN *

Exp *

Will you be adding claimant details?

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

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
By checking this box I acknowledge that this qualifies as my electronic signature that I accept the clinic cancellation policy.

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.

Numbers

Name