ICP New Client Intake Form

Please complete and submit this form prior to attending your appointment. All information will be stored confidentially and only shared with your Psychologist.

Important: This form must be completed and reviewed before an appointment is considered confirmed. It is the discretion of the treating Psychologist to confirm this appointment and also determine whether the treatment is completed in person or remotely.

First Name

Last Name

Email

Date of Birth

Mobile

Address

Medicare Number

Expiry

Reference #

If you are eligible for a MHCP Medicare Rebate, and you would like us to process your rebate for you, please provide preferred bank account details if Medicae does not have these already

BSB

Account Number

Please note: Medicare rebates only apply to individuals with a current and valid Mental Health Care Plan. ICP can only lodge your Medicare rebate claim; and does not control the Medicare rebate payment process into your bank account. If preferred, you can claim the Medicare rebate yourself after your appointment, by submitting your paid receipt directly to Medicare for review.

Next of Kin or Emergency Contact

Contact Phone

My nominated contact knows I am attending this appointment.

Referring Doctor (if applicable)

Are you experiencing any Covid or flu symptoms? *

No

Yes

Are you comfortable completing your appointment via Telehealth if required? *

No

Yes

Not sure, can we discuss

Are there any health conditions we should be aware of? *

No

Yes

Prefer not to say

Are you on any medications *

No

Yes

Prefer not to say

Further information on your health conditions/medications if applicable

Initials

I consent to ICP charging the credit card I supply for the session fee owing. Should I have not provided a credit card for payment, I agree to pay my account within the specified payment terms on my invoice (within 5 days).

I consent to ICP claiming my Medicare rebate on my behalf (if eligible) and agree that I have provided my correct bank account details for the Medicare rebate deposit.

I have read the ICP Covid Policy & Procedures document available and accept the terms & conditionsView Policy

I will not attend my appointment if I am unwell or have been in contact with recent Covid cases.

I understand as part of providing a psychological service, Incorporate Psychology (ICP) needs to collect and record personal information from you that is relevant to your situation, such as your name, contact information, medical history and other relevant information as part of providing psychological services to you. This collection of personal information will be a necessary part of the psychological assessment and treatment that is conducted. All information is treated as confidential and bound by the APS Psychologists Code of Conduct.

I understand that a cancellation (within 24 hours of my appointment) will incur a cancellation fee, unless it is the result of a proven health directive, or agreed to waive by the Psychologist.

Thanks for submitting this information.

info@incorporatepsychology.com.au | The Icon Centre Level 1, 15 Malt Street, Fortitude Valley Q 4006

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