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.

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT FOR ADULTS 18 YEARS AND OVER or WITH PARENTAL CONSENT for CHILDREN UNDER 18 YEARS (“AGREEMENT”)

1.I ACKNOWLEDGE, agree, and represent that I understand the nature of the APPOINTMENT I am about to have and that I am in reasonable health and state of mind to participate in such DISCUSSIONS.

I further agree that if at any time, the Counsellor/Psychotherapist/Social Worker believes the DISCUSSIONS or TOPICS to be unsafe for MYSELF or the Counsellor/Psychotherapist/Social Worker, The Counsellor/Psychotherapist/Social Worker reserves the right, at any time to discontinue the APPOINTMENT or reserves the right to change the direction of the APPOINTMENT topic. This ensures the Counsellor/Psychotherapist/Social Worker is working within the scope of professional, ethical and legal scope of practice. I am aware the Counsellor/Psychotherapist/Social Worker has professional Memberships/Accreditation, please see website for individual Memberships/Accreditation. Our Counsellor/Psychotherapist/Social Worker is personally, and as a company, covered with appropriate level of Insurance Certificates relevant to their professions.

2.I HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organisation(s), their administrators or Counsellors, Psychotherapist, Support Workers, Mental Health Educators or Support Coordinators for guidance given which may without intent cause an adverse situation, this APPOINTMENT is advice only and I understand I am responsible for my own actions and what I do with that said advice.

3. I understand that whilst information is confidential and bound by the confidentiality laws, I understand that there may be legal requests for my information to be shared and should the Counsellor/Psychotherapist/Social Worker be legally asked to disclose any information they will do so as per the law.

I ACKNOWLEDGE THAT I AM AGE 18 OR OLDER, or if the client is under 18 years old, I with parental knowledge sign and place my signature on this form.

4. I provide my consent for the use of Heidi, an AI-powered note-taking tool, to support and enhance the accuracy and efficiency of session documentation. I understand that this tool maintains strict standards of data privacy and security, including the use of advanced encryption to protect all information recorded.

BY READING AND UNDERSTANDING THIS FORM I GIVE MY CONSENT TO RECEIVE SERVICES FROM ESPHC. I CONFIRM I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS DOCUMENT, I HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I, THE ABOVE MENTIONED OR ON BEHALF OF MY CHILD, WILL INDEMNIFY, SAVE, AND HOLD HARMLESS, EACH OF THE RELEASES FROM ANY LITIGATION EXPENSES, ATTORNEY FEES, LOSS LIABILITY, DAMAGE, OR ANY COST THAT MAY OCCUR AS A RESULT OF ANY SUCH CLAIM.

PRINTED NAME OF PARENT/GUARDIAN (if participant is under the age of 18)

Phone Number of Parent/Guardian:

Client/Parent Guardian Signature

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Date:

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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