New Child/Young Person Client Form
and Developmental History Form

To save time at your appointment, please complete the relevent form below prior to your appointment.  
​Please review our Privacy & Practice information form as you wiill be asked to provide consent when submitting the information below.
Please discuss any queries you might have with your psychologist in the session,
alternatively call the office to discuss with Katherine.  
Please note, information submitted via the Family Minded website is encrypted with SSL security. 

First Step:
Please complete your child/young person's details here. 

    Please enter the Parent 1 Medicare details so we can process the Medicare rebate for you (if applicable)
    Privacy and Practice Policy Information
    Privacy Statement and Consent
    As part of providing a psychological service to you, your psychologist will need to collect and record personal
    information that is relevant to your current situation. Collection of personal information is a necessary part
    of psychological assessment and therapy. If you choose not to disclose personal information it will impact
    on the psychologist’s ability to provide you with a psychological service.

    ​Purpose of Collecting and Retaining Information
    Information is gathered as part of the assessment, diagnosis and treatment of a client's condition, and is
    seen only by the psychologist. The information is retained in order to document what happens during
    sessions, and enables the psychologist to provide a relevant and informed psychological service.

    Confidentiality
    With the exception of certain specific exceptions described below, your information will remain confidential
    and secure. All information collected for your psychological care are stored securely electronically on
    password protected computer, via HealthKit practice management software and Google Drive (professional
    version). There are circumstances when psychologists are required, by law, to break this confidentiality.
    This can occur when:
              1. The information you have given to your psychologist is subpoenaed (officially requested) by a
    court of law
             2. Failure to disclose the information would place you or another person at serious risk of harm
             3. Your prior approval has been obtained

    Social contact
    Some of our team live locally in the Sunbury area. Due to professional ethics, our psychologists do not
    connect via social media or personally with clients outside of their professional work roles. Were you/or
    your child (within age appropriate limits and expectations) and your psychologist to encounter each other in
    the community (e.g., at school or community event) your psychologist will respect your privacy and not
    approach you or discuss your personal information in public, but will be polite, interacting in a manner
    appropriate to the situation.

    Crisis Support
    This private psychology service does not have capacity to respond directly to crises. Please discuss your
    needs openly with your psychologist to ensure you have access to the support you need in between sessions.

    Accessing your Client Information
    A client has a general right of access to all information in their file, unless legislative requirements limit your
    access. If you wish to view and/or have a copy of the material recorded in your file then, by law, it is
    necessary to make the request in writing and send it to:
    Ms. Katherine Hill, 36 Gap Road, SUNBURY VIC 3429

    Fees and Cancellation Policy
    Private session fees can be paid by HICAPS/EFTPOS, or third party funding (e.g., HCWA, ATAPS, TAC, VOCAT).
    If you need to cancel or postpone the appointment, please give at least 24 hours notice, otherwise you will
    be charged a late cancellation fee of $50.00 to be paid prior to the next appointment.
    Please note, missed ATAPS sessions may result in cancellation of funding instead of late cancellation fee.

    Thank you for taking the time to complete this form

Second Step:
To maximise the use of your appointment time, please also complete the following Developmental History form. There is an option in this form for uploading digital copies of past assessments. Alternatively, you could email them to info@familyminded.com.au. Many thanks.  

Child Developmental History