Psychology Background Information Form

Please complete this form prior to your psychology appointment. It will be reviewed in advance to help us prepare and make the most of your session.

Patient Details

Date of Birth

Parent / Caregiver (Primary Contact)

Reason for Referral
Please tick as many as you require

Background Information

Medical Background

Social Background

Service Agreement

Psychological Services

As part of providing psychological services, we need to collect and record personal information from you that is relevant to your current situation. This information will be a necessary part of the psychological assessment and treatment that is conducted.

What information we collect

We collect personal and sensitive information necessary including your name, contact details, date of birth, health and assessment information, Medicare/NDIS details, and billing information. Where relevant, we may also collect information from parents, carers, referrers, or other health professionals.

How we collect information

Information is usually collected directly from you through appointments, forms, our website, or other communications. In some circumstances, and where lawful, information may be collected from third parties with your consent or as required by law.

You may choose not to provide certain information; however, this may limit our ability to provide services.

Why we collect and use your information
Your information is collected, used, and stored to:
• provide psychological services
• manage appointments, billing, and records
• communicate with you and relevant professionals involved in your care
• meet legal, ethical, and regulatory obligations
• improve our services and manage our practice

We may also contact you for appointment reminders and service-related updates. You may opt out of marketing communications at any time.

Confidentiality

All personal information gathered by the psychologist during the provision of service will remain confidential and secure. In most cases, any sharing of information will only occur with your consent. Your psychologist may ask for your consent to share information when:
• Sharing information with a parent, family member, guardian or carer.
• Discussing with others, such as your child's school, GP, or any other allied health services which may benefit from the collaborated support.
• Providing a written report regarding your assessment or treatment to another professional or agency.
• For disclosing the information in any other way not referenced in this document.

Psychologists are required to participate in professional discussions for the purpose of professional development. If your information is shared in this context, all care is taken to deidentify your information in such a way that you remain anonymous.

Exceptions to Confidentiality

There are times when your psychologist may release your information without obtaining your consent such as
1. It is required by law, or
2. Failure to disclose the information would place you or another person at risk, or
3. Your prior approval has been obtained to:
a) Provide a written report to another professional or agency (e.g. GP, lawyer), or
b) Discuss the material with another person (e.g. parent or teacher).

Storage and security

We take reasonable steps to protect your personal information from misuse, loss, or unauthorised access. Information is stored securely in electronic systems and, where applicable, locked physical files. Information no longer required is securely destroyed or de-identified.

Implications of Not Sharing 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.

Access and correction

You may request access to your personal information by contacting us in writing. We may require identity verification and may charge a reasonable administrative fee. Requests will be handled within a reasonable timeframe.

Fee Structure

All fees are payable on the day of service and may be paid by credit card or cash. Our session fees range from $240 to $260 per session depending on the clinician. We do not offer bulk billing. Current fees are available on our website. Please note that diagnostic psychological assessments, professional letters, assessment reports, court reports, and other written documentation attract separate fees, which will be discussed and agreed upon prior to commencement.

Cancellation Policy

If you need to cancel or reschedule an appointment, we kindly ask that you provide as much notice as possible. Cancellations made with less than 48 business hours’ notice will incur a fee of 50% of the scheduled appointment cost. Cancellations made with less than 24 business hours’ notice, including non-attendance without prior notice, will incur a fee of 100% of the scheduled cost. Please note that weekends and public holidays are not counted as business hours, as these times do not allow our administrative team to offer the appointment to another client.

To support you with planning, SMS appointment reminders are sent 7 days prior to your appointment. We appreciate your understanding and consideration of this policy.

Service Agreement Acknowledgement
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Patient Registration

Patient Details

Date of Birth

Address

Parent / Guardian (Primary Contact)

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Referring Doctor Details

Your payment details are stored securely to facilitate efficient billing for future services, including Telehealth consultations, prescription requests, and medical reports.  A $0.50 verification charge will be applied to your nominated card to confirm the payment method. In accordance with our Appointments and Fees Policy, full payment is required on the day of service. For Telehealth, payments are processed in advance to secure your booking. See Appointment and Fees Policy

Consent

At Brighton Health Clinic for Kids, we believe clear and respectful communication is essential to your child's health and wellbeing. We value your trust and work closely with families when making decisions about care and information sharing. To provide the best possible care, relevant information may be requested or shared with other professionals involved in your child’s health, development, or education.

Privacy Policy
Appointment & Fees
Separated Parents / Family Court Orders
Communications
Digital Scribing
Confirmation 1
Confirmation 2
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