PSYCHOLOGY

NEW PATIENT FORMS

Please complete the two forms below prior to your appointment. Press 'Submit' when you have completed each form. 

 INTOUCH HEALTH CO. - NEW PATIENT FORM
Psychology (Adult)
Title

Patient Information and Consent Form

 

Psychological Services

Psychologists provide a variety of services including psychological assessment and treatment for children, adults, older adults, and families with cognitive, behavioural, and emotional concerns. When you meet with your psychologist, the first couple of sessions will be devoted to carrying out a thorough assessment of your concerns. Then, you and your psychologist will together agree on treatment goals and develop a plan for therapy. Your psychologist will explain the treatment method considered and obtain informed consent, prior to commencing treatment.

 

Confidentiality

Only information relevant to your psychology treatment will be recorded and stored securely. This information may include your contact details, session notes, assessment material, treatment plan, supervision notes, and information from other health professionals (obtained with your consent). All information given in the process of psychological assessment and treatment is strictly confidential. No information will be released to others without your consent except in the case of; 

• Clinical notes requested by legal subpoena.

• If there is a risk of harm to yourself or to another person.

• To correspond with the referring doctor.

Payments

The services offered by your psychologist are provided on a standard fee for service basis. Fees are currently set at $160 per 50 – 60 minutes. This fee is payable at the time of consultation either by cash, credit, or EFTPOS. Rebates may be available through Medicare Better Access, or your private heath fund.

Medicare rebates Telehealth consults will be bulk billed as of 29/03/20 (require valid Mental Health Care Plan referral)

 

Cancellation Fees

If you cannot attend your psychology appointment, please notify your psychologist as soon as possible. Appointments cancelled without at least 24 hours notice are charged at 50% of the scheduled fee. Medicare does not cover cancellation fees.

 

Current Medicare Rebate: $86.15 (only available to patients with a valid Mental Health Care Plan from GP)

Your Signature

DASS 21 QUESTIONAIRE 

Please read each statement and select a number 0, 1, 2 or 3 which indicates how much the statement applied to you

over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

 

The rating scale is as follows:

0 Did not apply to me at all - NEVER

1 Applied to me to some degree, or some of the time - SOMETIMES

2 Applied to me to a considerable degree, or a good part of time - OFTEN

3 Applied to me very much, or most of the time - ALMOST ALWAYS

1. I found it hard to wind down
2. I was aware of dryness in my mouth
3. I couldn’t seem to experience any positive feeling at all
4. I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion)
5. I found it difficult to work up the initiative to do things
6. I tended to over-react to situations
7. I experienced trembling (eg, in the hands)
8. I felt that I was using a lot of nervous energy
9. I was worried about situations in which I might panic and make a fool of myself
10. I felt that I had nothing to look forward to
11. I found myself getting agitated
12. I found it difficult to relax
13. I felt down-hearted and blue
14. I was intolerant of anything that kept me from getting on with what I was doing
15. I felt I was close to panic
16. I was unable to become enthusiastic about anything
17. I felt I wasn’t worth much as a person
18. I felt that I was rather touchy
19. I was aware of the action of my heart in the absence of physicalexertion (eg, sense of heart rate increase, heart missing a beat)
20. I felt scared without any good reason
21. I felt that life was meaningless

Shop 16, 1 Raintree Way

Mount Annan, 2567

T: 02 4648 3500

F: 02 4648 5200

E: admin@intouchosteo.com.au

 

Shop 16, 1 Raintree Way

Mount Annan, 2567

T: 02 4648 3500

F: 02 4648 5200

E: admin@intouchosteo.com.au

 

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