New Client Enquiry Form

Client Enquiry Form

CLIENT DETAILS

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender

MaleFemale

English is a Second Language

YesNo

Ethnicity

ATSI

AboriginalTorres Strait IslanderNone of the Above

CLIENT CONTACT DETAILS

Home Phone

Mobile Phone *

Work Phone

Email *

Address *

Postcode *

City / Suburb

State

Preferred point of contact *

EmailPhone callsms

EMERGENCY CONTACT DETAILS

Name *

Address *

Postcode *

City / Suburb

State

Home Phone

Mobile Phone *

Email

Work Phone

MEDICARE

Do you use a different name in your medicare card?

YesNo

If you use Alias please write the Alias name & surname

Medicare First Name *

Medicare Surname *

Medicare Card No. Please include the individual reference number next to your name *

Expiry *

Medicare Address (if different to your residential address)

PRIVATE HEALTH INSURANCE

Do you have private Medical insurance

YesNo

Fund Name:

Fund Member Number:

Provider

Membership No.

Expiry

PENSION / HCC/DVA Card

Do you have an aged pension card, healthcare card or a DVA card

YesNo

Card Type

HCCPension

Card No.

Expiry(mm/yyyy)

DVA No.

Preferred Appointment Day and Time

Preferred Appointment Type

In personPhoneZoom

BILLING INFORMATION

Billing

PrivateNDIS

If private billing please refer to the practice manager for pricing

For all NDIS particpants please provide the following information

NDIS Number:

NDIS Provider

NDIS email address (for invoicing)

Any other NDIS revelant information such as Support Coordinator name and email for communication

If possible, please email a copy of the NDIS plan to admin@empoweredselfpsychology.com

PAYMENT OPTIONS
NDIS - Self and Plan managed, Eftpos, Cash, Afterpay, DCP (Department for Children Protection), Work Cover

IMPORTANT ADDITIONAL INFORMATION

To help us prepare for your initial appointment with one of our mental health professions, please provide a brief overview of why you are seeking additional support, any past experience you have had with therapy, and what you hope to achieve or address during your sessions. If NDIS please list NDIS goals within your NDIS plan *

PREPARING FOR YOUR INITIAL APPOINTMENT

Kindly arrive 10-15 minutes before your initial appointment to complete the necessary paperwork and settle your payment. If you need assistance with the forms, our practice manager or admin staff will be happy to help you.

LOCATION

We are located at Unit 2, Level 1, 83-85 Murray Street Gawler 5118.
For car parking, please enter from the corner of Calton Road and High Street for underground car parking.
Please find a link to our location below.

https://maps.app.goo.gl/uBo4pwLgJ5DfHAY87

PAYMENT AND CANCELLATION POLICY

Please find attached a copy of our payment and cancellation policy for your reference. Kindly note that late cancellations may be subject to the full appointment fee , and future appointments cannot be scheduled until any outstanding cancellation fees are settled. Thank you for your understanding

POLICY STATEMENT
Empowered Self Psychology & Holistic Centre is committed to providing exceptional service in a timely manner. Therefore, requires payment to be made either before or at the time of appointment, via bank transfer, EFTPOS, or cash.
Unfortunately, when a client cancels without providing sufficient notice, it prevents another client from receiving the support they need. No-shows and late cancellations impact the quality of service and can inconvenience clients who arrive on time. To ensure fairness and maintain high standards of care, Empowered Self Psychology & Holistic Centre has implemented a strict payment and cancellation policy.
FULL PAYMENT& CANCELLATION

Your appointment is complete when we receive your full payment. Payments can be bank transfer or in person
A confirmation text or message will be sent to you the day before appointment. This serves as confirmation of your appointment.
For NDIS clients we require 2 days notice of cancellation or full fee will be charged.
For Private clients we require 2 days notice of cancellation or full fee/cancellation fee will be charged.
First initial consults will be held on the premises (Unit 2, Level 1 83-85 Murray Street Gawler 5118), after initial consult home visits can go ahead if requested and approved from the Psychotherapist / Director.
Workshops require a deposit to hold a spot *Deposit amount varies and is stated on information flyer*
Our cancellation fee is charged at 100% of appointment cost if less than 24 hours’ notice.
Concession card holders must provide concession card on first visit to be able to receive concession rates.
Terms are if you pay for service bookings upfront you must use any money paid within 12 month period, after 12 months we have no liability to provide service.

We reserve the right to refuse clients who are displaying threatening or abusive behaviour, this includes verbal and physical. Any person displaying these behaviours will be asked to leave the premises and required services and police will be notified if required.

Cancellation requests may be submitted by phone, email or in person. If you have any questions or concerns about our cancellation policy, please contact the Practice Manager on 0422 652 297.

I have read, understand, and agree to comply with the foregoing policy, rules, and conditions. I am aware that violations of this may subject to legal action. Furthermore, I understand that this policy can be amended at any time. Thank you for your understanding.

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

Client Signature *

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Today's Date *

Patient/ Guardian Signature

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