Client Registration Form

Fees and Rebates

MEDICARE DETAILS

Medicare Card Number

Individual Reference Number (IRN)

Expiry Date (MM/YY)

FEES

Fees may include:

Session fees

Session fees are payable prior to the Telehealth or in person consultations by EFTPOS, Mastercard, or Visa. Please ensure you have sufficient funds in your account on the day of the consultation, prior to your appointment time. Any session fees due must be paid prior to or at the time of consultation. With your consent, we use a third party provider to securely and conveniently store your credit card for future transactions, in a secure and Payment Card Industry-compliant manner. Additional transaction bank fees apply to all payments. Please note that appointments before 9am or after 5pm incur a $10 surcharge.

Cancellations

Cancelled sessions will be billed as follows: 0-24 hours notice (50% of fee); 24-48 hours notice (25% of fee). Failure to attend with no notice will be billed at the full session fee. Cancellation fees will not be charged if no replacement service is billed for lost time.

I understand and accept the cancellation policy. I accept that it is my responsibility to ensure that there are sufficient funds available to cover fees owing to Hall Psychology & Coaching prior to each consultation. During the intake telephone conversation we ask all clients to provide their payment method to us prior to the initial consultation. I hereby authorise Hall Psychology & Coaching to charge the payment method stored for any fees owing.
*

I understand and accept the fee structure that has been outlined to me, including session fees, cancellation fees, and payment arrangements. If I am using NDIS funding, I accept that it is my responsibility to establish if there are sufficient funds to cover the costs of requested services provided by Hall Psychology & Coaching and that there are funds available to make a Service Booking for requested services. I accept that I am personally responsible for the fees for any services not covered by NDIS, including services for which there were: insufficient funds; services provided when no Plan was in place; fees not paid by a Plan Manager when requested; and any costs incurred in recovering outstanding fees. *

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PATIENT DETAILS

EMERGENCY CONTACT DETAILS

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MEDICARE DETAILS

FEES