Client Registration for Counselling Appointments

CLIENT REGISTRATION for COUNSELLING APPOINTMENTS

Please note that this form can be completed in more than 1 sitting.

To save progress, scroll down to the bottom of the page and press 'Save and Complete Later'.

You will be emailed a reminder link.

First Name *

Surname *

Today's date *

Preferred to be addressed as *

Gender *

Date of Birth *

Mobile number *

Please indicate if a message can be left at this number *

YesNo

Alternative contact number

Please indicate if a message can be left at this number

YesNo

Postal Address *

Residential Address *

Email *

Please indicate if a message can be left at this email address *

YesNo

Session logistics

How many sessions are you anticipating needing to achieve your goals? *

1-2 sessions3-6 sessions7-10 sessionsmore than 10 sessions

How frequently would you like sessions? *

Preferred location for counselling *

In-person / EuroaIn-person/ MelbourneTelehealth (video and audio)Telephone

Mental Health Care Plan

Do you have a current Mental Health Care Plan from an Australian Doctor? *

YesNo

Referring GP

Clinic address

Do you consent to your GP receiving feedback regarding your mental health? *

YesNo

As a condition for Medicare rebated sessions under the Medicare Benefits Scheme, psychologists are required to provide your GP with feedback regarding your mental health and participation in counselling.

Please upload your Mental Health Care Plan here

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Medicare number *

Expiry date *

Private Health Fund(if relevant)

Private Health Fund membership number(if relevant)

Information helpful for providing this service

Are you currently prescribed any medications relevant to your mental or emotional health? *

YesNo

Name of drug and in what dosage?

Have you consulted any other mental health professional in the past 10 years? *

YesNo

How long ago and for what reason?

Is English your first language? *

YesNo

Are there any specific cultural preferences or requirements that would help you to feel more comfortable and respected in the counselling session? *

YesNo

Please provide details as relevant

Do you have any particular mobility, language or other needs? *

YesNo

Special requirements - outline

Any other comments or preferences to enhance the counselling service for you? *

YesNo

Please detail as relevant

What is helping you to cope with your situation currently? *

Your goals for attending

What are your specific goals for seeking counselling or psychotherapy at this time? *

What will be indications to you that your goals have been achieved? *

Psychosocial screen

DASS

Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

The rating scale is as follows:

0 Did not apply to me at all - NEVER

1 Applied to me to some degree, or some of the time - SOMETIMES

2 Applied to me to a considerable degree, or a good part of time - OFTEN

3 Applied to me very much, or most of the time - ALMOST ALWAYS

List current main sources of stress in your life *

What is your usual & main occupation? *

Detail if you would like to

Anything else?

Write your comments or questions here. We will email a response to any questions.

Landing here

Elaborate if you choose to

EMERGENCY ONLY

Next-of-kin or preferred contact

To contact ONLY if you do not turn up for your appointment and cannot be contacted, or in case of an emergency

Name *

Relationship to you *

Mobile number *

Please indicate if a message can be left at this number *

YesNo

Do you have any allergies or potentially life-threatening conditions? *

YesNo

If so, please provide details of usual emergency support plan and/or GP's contact number

Health caution

Please do not opt for an in-person appointment if you are unwell or if you have been in contact with anyone in the past 14 days who has symptoms of COVID or any other communicable illness. You can always rebook your appointment.

On arrival at the clinic, please use the sanitizer available.

The counselling room is airconditioned at all times and air quality is supplemented by an air purification device.

A Perspex screen can be put in place to act as a 'sneezeguard' to help minimize the sharing of droplets, for example through sneezing or coughing.

Thank you for being mindful of your own health and the health of those less vulnerable than yourself in a health facility setting.

Informed consent

This document describes the policy of the practice of Esse Psychology/The Humanitarian for the management of client information. The psychological service provided is bound by the legal requirements of the National Privacy Principles from the Privacy Amendment (Private Sector) Act 2000. Esse Psychology abides by the Australian Psychological Society's Charter.

Consent for service

Your consent is required for us to provide a psychological service. Your psychologist will explain to you the benefits and any potential risks of accessing psychological services. Please ensure that you fully understand the service information provided and ask for further information if you are unclear as to the information outlined in this consent form.

Personal Information

As part of providing a psychological service, such as a psychological assessment or treatment, we will need to collect and record personal information that is relevant to your current situation. This information is a necessary part of the services provided and guides treatment. You do not have to give all of your personal information, but choosing not to share your relevant information may mean that the psychological service may be affected.

Purpose of collecting & holding information

Your personal information is gathered as part of the assessment, management and treatment of a client’s situation and condition at the time of seeking psychological service provision and is seen only by the consulting psychologist.

Your information will be confidentially retained to document what happens during sessions and enable the psychologist to provide a relevant and informed psychological service to you.

Information storage

Your information is stored securely. Client files are held in secure filing cabinets, password protected hard drives & secure electronic systems which are accessible only to the consulting psychologist, or in the event of any significant injury, permanent disability or death of your psychologist, by authorised personnel. The information on each file includes personal information such as name, address, contact phone numbers, and other information which is relevant to the psychological service being provided.

Consequences of not providing personal information

Psychologists are required to keep clear and accurate client records as part of their professional obligations. If you do not wish for your personal information to be collected, we may not be able to provide the psychological service to you. Please discuss any concerns you have with your psychologist.

Requests for access to client information

At any stage, you as a client are entitled to access the information about you kept on file, unless the relevant legislation provides otherwise. The consulting psychologist may discuss with you, appropriate forms of access, for example by discussing the contents with you. All requests by clients for access to information held about them should be lodged with esse@essepsychology.com.au or psy@thehumanitarian.com.au. These requests will be responded to within 30 days and an appointment will be made if necessary, for clarification purposes.

Confidentiality of information

Personal information gathered by your psychologist will remain confidential except for certain circumstances. In most cases, any sharing of information will only occur with your consent. Our practice asks for your consent to share information when:

Sharing information with a family member, guardian or carer.
Discussing with others, such as your GP, employer, or any agencies which may be paying for your attendance.
Providing a written report regarding your assessment or treatment to another professional or agency, such as your GP, lawyer or insurance company.
For disclosing the information in any other way not referenced in this document.

Psychologists are required to consult and receive supervision from colleagues from time to time. If your information is shared in this context, all care is taken to deidentify your information in such a way that you remain anonymous.

Exception to confidentiality

There are times when your psychologist may release your information without obtaining your consent such as:

When a court requires information by issuing a subpoena, or providing information is otherwise required or authorised by law.
When it is required because the psychologist must make a mandatory report on a concern.
When the psychologist discloses information because they believe you or someone else is at risk of serious harm.

Fees

The cost of a 50-60 minute counselling consultation is $240 (which is below the APS recommended fee of $318).

Fees increase by increments of $50 for every 15 minutes thereafter.

At the end of each appointment, you will be invoiced. Once you have paid the invoice in full (either on the day by credit card or within 3 days of the appointment by Electronic Fund Transfer), your invoice will be receipted and you will be able to claim a rebate with either Medicare (if you have a GP referral & mental health care plan) or via your private health fund if you are covered for extras.

Cancellation policy

If, for some reason, you need to cancel or postpone the appointment, please give Esse Psychology/The Humanitarian at least 36-24 hours/ 1 days’ notice. The more notice that is possible, the better, for other clients wanting to schedule an appointment. If you regularly forget or cancel your appointments at very short notice, you will likely be requested to pay a cancellation fee equivalent to the cost of a session.

How to make a complaint

If you have any concerns about your contact with our clinic, please discuss these with your psychologist, if you are able. If you would like to make a complaint, you are able to do so by contacting us either by phone or in writing to Esse Psychology/The Humanitarian (esse@essepsychology.com.au or psy@thehumanitarian.com.au)

APS Charter for Clients of Psychologists

The attached Charter explains your rights as a client of a psychologist.

Period of consent

This consent is provided for the following time period. Consent will also be reviewed as required should the terms of the service change.

Consent is valid until this set date: 31/12/2026

You have a right to withdraw this consent at any time by telling your psychologist or putting your request in writing. You cannot withdraw consent for a service that has already occurred. Your psychologist can discuss with you any implications of withdrawing consent.

Please Note: If, after reading any documentation, you are at all unsure of what is written or how to interpret it, please email esse@essepsychology.com.au to discuss any aspects of the service that has not been made clear to you prior to your first consultation.

I, (Client's full name) *

... have read and understood the contents of this consent form and the information provided to me during the consent process. I agree and consent to the conditions above for the psychological service provided and have noted I can discuss any outstanding questions with the practice/ psychologist before commencing service.

I agree to the conditions for psychological services to be provided.

Client name *

Client signature

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Date

24 HOUR & OTHER COUNSELLING NUMBERS

If you are needing more immediate assistance, there are a number of services that offer 24-hour support.

LIFELINE 13 11 14

BEYOND BLUE 1800 512 348

MEN'S LINE 1300 78 99 78

13YARN 13 92 76 (Aboriginal & Torres Strait Islander Crisis Support)

Switchboard Victoria (LGBQTI) 1800 184 527

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