UNIQUE BRAINS
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(03) 4335 5201

New Client Referral Form

Client Details

Client Contact Information

Reason For Referral

Do You Have A Current Mental Health Care Plan?

If you selected YES or IN PROCESS, then proceed to Referring Doctor Details.
If you selected NO, then proceed to
Health Cover Details.

Referring Doctor Details

Health Cover Details

NDIS Participant:

Agency Referral:

Other Referral:

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 at least 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 $100 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 $200 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.

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