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. 
How We Work With Children

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)
    Max file size: 20MB
    If none of these options above apply, we may not be able to see your child. Please contact the office to discuss with the principal psychologist, Katherine Hill.
    Privacy, Policy and Consent
     
    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 and disclosure of personal information
    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 Halaxy practice management software and Google Drive (professional version). 
    ​
    Personal information gathered as part of this service will remain confidential except when:
    1. it is subpoenaed by a court; or
    2. failure to disclose the information would place you or another person at serious risk to life, health or safety; or
    3. your prior approval has been obtained to
    • provide a written report to another professional or agency. e.g., a GP or a lawyer; or
    • discuss the material with another person, e.g. a parent, employer or health provider; or
    • disclose the information in another way; or
    1. you would reasonably expect your personal information to be disclosed to another professional or agency (e.g. your GP) and disclosure of your personal information to that third party is for a purpose which is directly related to the primary purpose for which your personal information was collected; or
    2. disclosure is otherwise required or authorised by law.
     
    Provision of a telehealth/online therapy service
    Where appropriate the service may be provided by telephone or videoconferencing. You are responsible for the costs associated with setting up the technology needed so you can access telehealth services. Family Minded will be responsible for the cost of the phone call to you and the cost associated with the platform used to conduct telehealth services.
    To access telehealth consultations you will need access to a quiet, private space; and the appropriate device, i.e. smartphone, laptop, iPad, computer, with a camera, microphone and speakers; and a reliable broadband internet connection.
    The privacy of any form of communication via the internet is potentially vulnerable and limited by the security of the technology used. To support the security of your personal information this practice uses Coviu and Zoom which are encrypted.

    Limitations of telehealth/online therapy
    A telehealth consultation may be subject to limitations such as an unstable network connection which may affect the quality of the psychology session. In addition, there may be some services for which telehealth is not appropriate or effective. Your psychologist will consider and discuss with you the appropriateness of ongoing telehealth sessions.

    Separated families
    We require both parents to be aware of and supportive of us seeing children, unless there are exceptional circumstances (see How We Work With You link above). We expect that parents will work reasonably cooperatively and communicate appropriately together about their child's needs and psychological assessment, recommendations and treatments.  
    Failure to do so may result in us withdrawing our services.
     
    Requests for reports
    We do not write reports for court.
    We do write clinical review letters to GPs as part of Mental Health Care Plans.
    Other reports maybe prepared as requested and attract fees. Due to our heavy work load, we need several weeks notice to prepare reports, especially if they require specific screening/testing. GST applies to reports.

    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
    Session fees can be paid by HICAPS/EFTPOS, or third party funding (e.g., HCWA, CAREiMIND, TAC, VOCAT, NDIS). 
    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 (+GST) to be paid prior to the next appointment.
    Please note, missed CAREinMIND sessions may result in cancellation of funding instead of late cancellation fee.

    Thank you for taking the time to complete this form

Please ensure you also complete the Child Developmental History form, and the NDIS info form if you are accessing NDIS funding.