New Client and Referral Form

Before filling out this form, please read the relevant page(s) on this website that relates to the service(s) you require.

Enter the details of the person requiring the service:

Client Details

Contact Information

Requested Service

Select one or more of the following requested services:

Reason For Requested Service

Referring Doctor Details

Medicare Details

Do You Have A Current Mental Health Care Plan (MHCP)?

Health Cover Details

NDIS Participant:

Agency Referral:

Other Insurers:

Let Us Know

Appointment Cancellation Policy

If, for some reason, you need to cancel or postpone your appointment (e.g., due to illness), please give the Psychologist at least 24 hours’ notice.  If you cancel a standard consultation appointment with greater than 24 hours notice, then a cancellation fee will not apply.  If you cancel an appointment at short notice, i.e., less than 24 hours before the appointment, then you may be charged a 50% cancellation fee.  If you fail to attend a scheduled appointment, with no notice of cancellation (e.g., forgot), then the full consultation fee may apply.  There are no Medicare or other rebates available for missed appointments. 
 
If you wish to cancel an appointment involving a psychological assessment, please provide at least 48 hours notice of cancellation, otherwise a $110 cancellation fee may apply.  If you fail to attend a scheduled assessment appointment, with no notice of cancellation (e.g., forgot), then the full standard consultation fee of up to $220 may apply.  There are no Medicare or other rebates available for missed appointments. 
 
If a cancellation was made due to unavoidable circumstances, then we will do our best to reschedule the appointment but it will be at the discretion of Unique Brains to determine whether cancellation fees apply.  If two consecutive short notice cancellations are made, then it is also at our discretion to either charge a non-refundable deposit for future sessions, or decline to offer further appointments.

Verification And Submit

Autoreply
From
Subject
HTML Body