Client Registration Form & DASS 21 - The Three Seas Psychology

Client Information

Name*

First Last

Email*

Date of Birth*

Are you / is the client under 16yrs of age?*

Yes
No

Parent/Guardian Information

Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone*

Has the client seen a psychologist in the last 12 months? If yes, how many sessions did they have?

In a few words, tell us about the reason for your visit? (optional)

This information will be sent directly to your psychologist.

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Emergency Contact: (name and contact number)*

Did you receive a phone call from your treating psychologist prior to your appointment?*

Yes
No

Has the client seen a psychologist in the last 12 months? If yes, how many sessions did they have?

In a few words, tell us about the reason for your visit? (optional)

This information will be sent directly to your psychologist.

Are you seeing us through an EAP agreement?*

Yes
No

EAP is an employee assistance program. The Three Seas must have an active contract with your employer in order for the program to proceed.

What is the name of the organisation you are employed by?*

I hereby authorise the Three Seas Group to provide the following information to my employer:

The scheduling of my appointments for the purpose of payment

De-identified demographic details as part of a monthly report

No other information will be provided to my employer or any other third party without written permission from myself or in a circumstance outlined in The Three Seas Psychology Group Personal and Confidential Information policy.*

I acknowledge that my employer is committed to the provision of contracted number of appointments. If further sessions are approved by my employer, these sessions will also adhere to the above disclosure guidelines.

Payment of Appointments

Your employer will fund a contracted amount of sessions per calendar year. A fee applies for all additional consultations. The Three Seas Group requires appointments to be paid in full at the time of your consultation. A 2% 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. This is a formal agreement between you and The Three Seas Group and consists of a payment plan to satisfy your debt. Please note that our consultation fees are subject to change on an annual basis.

I accept that the service provided by The Three Seas Group is to be paid in full at the time of the service.

I consent to entering into a Payment Plan Agreement in the event that I’m unable to make payment in full for the service rendered to me.

HOW DID YOU HEAR ABOUT US?*

Medicare Claiming

You will only be eligible for a Medicare Rebate if you have an active Mental Health Care Plan. If such a plan is in place, we will process your rebate electronically at the time of payment. Please note that the processing time for this is usually between 24-48hrs, and the rebate will be directed into the bank account details you have stored with Medicare (ie, not necessarily the card you pay with). If you are concerned that the details held with Medicare are out of date, we recommend you contact them on 132 150.

Do you have a Mental Health Care Plan?*

Yes
No

Medicare Number*

Please note: we cannot process your rebate unless we have your Medicare card.

Medicare Card Expiry Date*

Individual Reference number (IRN):*

This is the number to the left of your name (it indicates what number you are eg. on a joint Medicare card)

Medicare Electronic Claiming*

Tick this box if you give permission for The Three Seas Group to submit the Medicare Claim on your behalf.

I grant permission to The Three Seas to claim through Medicare on my behalf.

Upload your Mental Health Care Plan

Max. file size: 24 MB.

If you already have a Mental Health Care Plan (MHCP), please upload it now so that we can ensure your rebate is processed on the day of your appointment. If you are unable to do so prior to you appointment please proceed with the rego form without uploading your MHCP. Please note: we are unable to process Medicare rebates unless the MHCP is signed by the client (you) and the referring Dr.

Payment of Appointments

The Three Seas Group requires appointments to be paid in full at the time of your consultation or prior. A 2% 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. This is a formal agreement between you and The Three Seas Group and consists of a payment plan to satisfy your debt. Please note that our consultation fees are subject to change on an annual basis.

I accept that the service provided by The Three Seas Group is to be paid in full at the time of the service.

I consent to the fees for my appointments being charged automatically to my credit card, along with a 1.5% + $0.25 surcharge.

I consent to entering into a Payment Plan Agreement in the event that I’m unable to make payment in full for the service rendered to me.

Non Attendance Fee

Your appointment time is reserved for you. If you wish to change or cancel your appointment, we require you to give us at least 48 hours (to the hour) notice, otherwise a cancellation fee will be charged. Appointments cancelled or rescheduled within less than 48 hours will incur 50% of the appointment fee. Appointments cancelled or rescheduled within less than 24 hours will incur 100% of the appointment fee. Our practice(s) usually have a waitlist of clients who are in need of support. If you fail to provide adequate cancellation notice or do not attend, other clients who could have been seen at that time miss out. Having said this, if we are able to fill your appointment time with another client on our waitlist; you will not incur a cancellation fee. When possible, an automated text reminder will be sent 72 hours before your scheduled appointment; however, this is a courtesy only and subject to the functionality of our client management system. It is your responsibility to record and remember the timing of any appointments you make. 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. Voicemails can be left over the weekend/public holidays. The non attendance fee is a fee associated with all cancellations, rescheduling or non-attended appointments and applies irrespective of the reason. The fee will be charged to your credit card in line with the terms stated above.

Acknowledgement of Policy*

I hereby acknowledge the above Non-Attendance Fee Policy and accept that I will be charged 50%-100% of the appointment fee if I do not give 24-48 hours notice to cancel, reschedule, or when I do not attend my booked appointment.
I consent to providing my credit card details to The Three Seas Group and understand that my information will be saved to file for future transactions.

Please indicate that you have read and understood the above policy

Nominate Partial Consent

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 the name below you provide permission for this person to (only) discuss appointment times and billing queries with The Three Seas Group :

Name and contact details :

Provision of Psychological Services

Please refer the the following page for information about what to expect from Psychological Services in Australia. This page pertains mostly to confidentiality and disclosure of personal information. https://thethreeseas.com.au/confidentiality-and-disclosure-of-personal-information/ After reading this, please proceed to acknowledge consent of these conditions.

Acknowledgement and Consent

I have read and understood the above Confidential Client Registration and Consent Form. I agree to the above conditions for the psychological service provided by The Three Seas Group.