Client Registration Form & DASS 21

Client Registration Form

  • Emergency Contact:


    As part of providing a psychological service, The Three Seas Group will need to collect and record personal information from you that is relevant to your current situation. This information will be a necessary part of the psychological assessment, diagnosis and treatment that is conducted. The information is retained in order to document what happens during sessions, and enables the psychologist to provide a relevant and informed psychological service. All personal information gathered by the psychologist during the provision of the psychological service will remain confidential and secure except where: 1. It is subpoenaed by a court; 2. Failure to disclose the information would place you or another person at serious and imminent risk; 3. Your prior approval has been obtained to: a) provide a written report to another professional or agency. eg. a GP or a lawyer; b) discuss the material with another person, eg. a parent or employer. 4. Disclosure is otherwise required or authorised by law.
  • The Three Seas Group treats any information about you with the highest level of confidentiality. However, you can nominate any person that can contact The Three Seas Group on your behalf. By listing a name below you provide permission for this person to (only) discuss appointment times and billing queries with The Three Seas Group:
  • As part of providing a quality service, the Australian Health Practitioner Regulatory Agency requires that psychologists engage in regular clinical supervision. If discussed, all information that may identify you is kept confidential. Finally, recording of face to face/phone or Skype consultations is not permitted.
  • Tick the box below to permit The Three Seas Group to submit Medicare Claim(s) on your behalf. The rebate is only accessible with a valid Mental Health Care Plan (MHCP) and will be reimbursed into your bank account known to Medicare.
  • The Three Seas Group requires for all appointments to be paid in full at the time of your consultation. A 1% surcharge applies to all payments made by Credit Card. The Three Seas Group works on a prepayment basis and you are expected to make payment for your session prior to the service. If for any reason you are unable to make the payment prior to or immediately after the service, you are required to enter into a Payment Plan Agreement, which is a formal agreement between you and The Three Seas Group and consists of a payment plan to satisfy your debt.
  • Your appointment time is reserved for you. If you wish to change your appointment, we require you to give us at​ ​least 48​ ​hours​ (to the hour) notice. Amendments to appointments must be made via phone, voicemail or email - not text message. In times when the phone is unanswered, please leave a voicemail advising us of your change in appointment. Appointments changed with less​ ​than​ ​48​ ​hours​ notice may incur a $100​ ​appointment​ ​fee​. The appointment fee is a fee associated with all cancellations, rescheduling or non-attended appointments and applies irrespective​ ​of​ ​the​ ​reason​. The appointment fee will be charged to your credit card if less than 48 hours notice is provided. Please note that if less than 48 hours notice is provided, other clients miss out on obtaining the psychological services they require. To assist you, a text reminder is sent out 72 hours prior to the appointment. However, this is a courtesy and you are ultimately responsible for the appointments booked. Medicare and in most cases private health insurers do not provide rebates for cancellation or non-attendance fees.