Make a Booking – Adults

* Your Name
 male female
* Date of birth

* Address

* Phone

* Email

Marital Status ---SingleMarriedDe FactoOther

* Emergency Contact / Next of kin

* Phone

Who referred you to Pathways?

Your Occupation

What are your main reasons for coming to Pathways?
(select more than one option using the Ctrl key)
Resilience SkillsWork IssuesHealth IssuesSport PsychologyStress Management Family ChallengesOther
Have you seen health professionals previously regarding these matters?
 yes no
If yes, please briefly describe:

Please give a brief description of your medical history (e.g. significant hospitalisations etc.)

Please briefly describe any significant physical/psychological health problems within your family

Please briefly describe your strengths

Any other notes or important information

* Are you claiming through Private Health or Medicare?
---NoYes, Private Health Yes, Medicare (I have a GP Mental Health Care Plan or referral from my paediatrician / psychiatrist)
Name of insurance provider

If you would like, you can upload your Mental Health Care Plan Here (alternatively, you may bring this along to the initial session).

Please upload any other relevant information (e.g. Referrals, previous psychological reports, teachers’ reports, etc.) you may also bring these along to the initial session if you prefer.

* My Booking I have made an appointment at Pathways, and am filling this out as my intake formI have not made an appointment, and would like a staff member to contact me to make a booking

..

Pathways Health and Research Centre is aimed at promoting resilience and life skills in individuals, families, and school communities. This is achieved through individual and group programmes which focus on strategies helping you to overcome life’s challenges. Our clinicians take a positive, strengths-based approach using evidence-based interventions, empowering people to be resilient for life.

In addition to our individual & group services, Pathways Health & Research Centre is actively involved in ongoing research, to ensure the most effective techniques are being employed for you and your family.

For immediate assistance, please call Lifeline on 13 11 14.

Please read our Service Agreement, and indicate your consent to the terms below:

PATHWAYS HEALTH AND RESEARCH CENTRE SERVICE AGREEMENT

Pathways Health and Research Centre is committed to providing quality services. These terms of service have been drafted to ensure that the welfare of all our clients is protected, and to ensure that we are able to provide your family with professional services of the highest standard.

Please read the following terms of service carefully, and discuss and questions you may have with your psychologist.

1. All information provided is confidential. We will not disclose any information about you or your family to any other agency or person without your written permission with the exception of disclosure of illegal activity or if we are ordered by a court or other legal service. If we feel that there is a threat to the safety of someone in your family, or to someone else, then we may disclose some confidential information. In the unlikely event that this should happen we will make every effort to discuss this with you prior to making any disclosure.

2. Your written permission will be sought if (a) we are asked to provide information about your family to any external agency or person involved with your care unless we are ordered by a court or other legal service, or (b) if we would like to obtain information about your child or family from an external agency or person.. You will be notified prior to any correspondence sent from our service regarding your child or family.

3. Privacy and confidentiality for our clients is a priority. We insist that this confidentiality be extended to all our clients. If you know another child of family who uses our service please protect their privacy at all times. Protection of your privacy is also ensured this way.

4. We ask all clients to participate in an assessment before the commencement of therapy and another following the completion of treatment. In some cases, the person undertaking the assessments will be different from the therapist involved in treatment. This is to your benefit as it ensures that the assessment process does not interfere with your child’s relationship with their therapist.

5. Assessment information gathered before and after the completion of treatment will be utilised for evaluation purposes and future research into client outcome at the clinic. All identifying information and names will be removed from the assessments before their use for research and will remain completely confidential. You have the right to withdraw your participation in this research at any time without penalty.

6. It may be necessary sometimes for our service to communicate with other people or agencies involved in your child’s care (e.g. schools or other health professionals). This form of communication may include e-mails, telephone calls and/or letters. In the event that we are required to participate in a face-to-face meeting with other people or agencies the travel and meeting time will attract an hourly fee that is charged in accordance with the Schedule of Fees provided by the Australian Psychological Society.

7. Pathways Health and Research Centre is not a crisis or emergency service and we do not have the resources to respond to such a situation. In the event that your family is in crisis, we recommend telephoning Lifeline (13 11 14), the police, or your local hospital emergency department.

8. We will make every effort to respond to a telephone call within 48 hours of receiving a call. In certain circumstances your psychologist may be unable to return your call within this time period and our office administrator will telephone you to advise you that there will be a delay.

9. We kindly ask that all consultations be scheduled in advance. If telephone consultations are required, they will be scheduled and a consultation fee will be charged.

10. All fees are to be paid at the time of consultation. We accept payment by cash or cheque, and merchant facilities are also available.

11. A cancellation policy has been established of $50 if an appointment is cancelled within 24 hours of the scheduled time. This policy will not be applied if the cancellation is due to illness or other extensive circumstances.

12. The Australian Psychological Society Code of Ethics was developed to promote sound professional practice and to safeguard the welfare of clients and their families. All our psychologists are bound by the Code of Ethics. If you would like to see a copy, please ask our office staff.

13. If you have any concerns or complaints about the service you receive, please feel free to discuss them with your therapist. Alternatively you may speak to one of the Pathways Health and Research Centre directors, Dr Paula Barrett, or Dr. Sacha Rombouts.

14. Your credit card details will be collected on your first appointment. If for some reason the account has not been paid or there has been a cancellation fee applied in alignment with the cancellation policy listed in the agreement below, the outstanding amount will be deducted from your credit card. In this case, you will be notified immediately after the payment has been recorded via phone or text and the invoice will be sent directly to you via post.

I Agree to the terms of service outlined above.
* Your Name

* Date

Thank you so much for choosing Pathways Health & Research Centre. We very much hope your experience will be a rewarding one.
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