Client Information & Consent Form

Client Information


Postal Address


Next of Kin

Emergency Contact

Medical Information

Do you have a current Mental Health Treatment Plan?

Have you used any of your allocated appointments?

Are you an NDIS client?

Are you claiming through Worker’s Compensation?

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

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

Do you have Private Health Insurance?

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 ( 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

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.

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


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.

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