SELECTABILITY

Client Information & Consent Form

Client Information

Family Name

First Name

Middle Name

Preferred Name

Date of Birth

Address

Street Address

Suburb

Postcode

Postal Address

Postal Address is different from Street Address

Street Address

Suburb

Postcode

Mobile Phone

Work Phone

Email

Occupation

Consent to SMS appointment reminders?

YesNo

Do you identify as

AboriginalTorres Strait IslanderAboriginal and Torres Strait Islander

Do you identify as

South Sea IslanderDo not wish to identify

Other cultural identity

Country of Birth

Language spoken at home

Do you require an Interpreter?

YesNo

Sex

FemaleMaleOther

Gender identity(optional)

Medicare Number

Expiry Date

Individual Reference Number

Next of Kin

Name

Contact Number

Street Address

Suburb

Postcode

Relationship to you

Emergency Contact

Different to Next of Kin

Name

Contact Number

Relationship to you

Medical Information

Usual Doctor (GP)

GP’s Practice

Do you have a current Mental Health Treatment Plan?

YesNo

Expiry Date

Have you used any of your allocated appointments?

YesNo

How many?

Are you an NDIS client?

YesNo

NDIS Number

NDIS Service Provider/Support Coordination

Provider Contact Name

Provider Contact Number

Are you claiming through Worker’s Compensation?

YesNo

Claim Number

Insurer

Case Manager

Do you have a DVA (Dept. of Veteran’s Affairs) card?

YesNo

DVA Number

Type

WhiteGold

Do you access VVCS Assistance?

YesNo

Are you a member of the Australian Defence Force (ADF) and been referred by ADF?

YesNo

PMKEYS

DAN

Do you have Private Health Insurance?

YesNoN/A

Private Health Fund

Member Number

Payment Policy

If your 3rd Party Insurer (WorkCover, DVA or Other) declines to pay for your treatment, selectability will invoice you, the client. We require prompt settlement of your account within 7 days. Payment plans can be arranged on request.

In order to bulkbill we must be supplied with a valid referral from your treating GP and valid Medicare number. If payment is declined through bulk billing, selectability will invoice you, the client. We require prompt settlement of your account within 7 days. Payment plans can be arranged on request.

Non-Attendance / Cancellation Policy

To ensure we can provide timely treatment to you and others we ask that you provide us with reasonable notification of cancellation 24 hours prior to booked appointments. We will make all efforts to accommodate your needs and supply you with the details of your appointments at time of booking and via text message reminders. However we take no responsibility for text message reminders that are not received. If you are not able to provide adequate notice of cancellation or if you do not attend your appointment you may incur a $50 fee. This fee will be charged to your account and will need to be settled prior to subsequent appointments.

Privacy Collection Notice

Under the Privacy Act 1988 (Privacy Act) we at selectability are required to provide you with certain information as to how we protect your privacy and how we comply with the requirements of the Act and the 13 Australian Privacy Principles (APP’s). This information is set out in our Privacy Policy which is available on our public website at (www.selectability.com.au) and also available upon request in hard copy from our business office.

Our Privacy Policy describes:

who we collect information from;
the types of personal information collected and held by us;
how this information is collected and held;
the purposes for which your personal information is collected, held, used and disclosed;
how you can gain access to your personal information and seek its correction;
how you may complain or inquire about our collection, handling, use or disclosure of your personal information and how that complaint or inquiry will be handled; and
whether we are likely to disclose your personal information to any overseas recipients

We recommend that you read our Privacy Policy and if you have any queries about its contents, you can contact our Privacy Officer at feedback@selectability.com.au

Sharing information

By signing this consent form you authorise selectability to use, store, release and exchange your information with selectability contracted Mental Health Professionals, other service providers, health and medical practitioners and other government agencies to support the services we provide to you and to comply with selectability’s legal obligations.

Use of your personal information for selectability marketing purposes

In some circumstances selectability may want to use your personal information (such as your contact details) to send you newsletters or promote other services that relate to the service being provided to you by selectability. You have the right to ask selectability not to use your information to send you newsletters or promotional information.

If you do not want selectability to use your information to promote products or services that are related to the services you receive from us please tick the box below.

I do not want selectability to send me newsletters or information about other services.

If, at any time, you change your mind about receiving marketing information from us you can email feedback@selectability.com.au or speak to a selectability staff member.

Consent

By signing this consent form:

I understand that my information will be managed in accordance with the Privacy Act

I understand that my information may be de-identified and used by selectability for statistical purposes under the management of the program that funds this service.

Name

Date

Signature

Draw signature|Type signatureClear

or Verbal Consent which has been given as per verbal consent protocol

Name

Telephone number

Date of Verbal Consent

Password