Hall Psychology New Client Intake & Consent Form

SECTION 1: CLIENT REGISTRATION

CLIENT DETAILS

First Name *

Preferred Name

Last Name *

Date of Birth *

Gender *

MaleFemaleOther

Mobile Phone *

Home Phone

Work Phone

Email *

Address *

City / Suburb *

State *

Postcode *

Referred by / How did you find us? *

Preferred appointment times? (e.g. Tues before 5pm) *

EMERGENCY CONTACT DETAILS

Prior to commencement of any Telehealth services (telephone or videoconference) we need to have the contact details of support people in your local area should any issues of risk arise. Please provide the name and contact details of one person known to you before we commence treatment (for example next of kin, family, friend).

First Name

Last Name

Mobile Phone

Relationship (e.g. Partner, Parent, Friend)

SECTION 2: INTAKE INFORMATION

CONSULTATION

Reason for seeking support? (e.g. depression, anxiety, insomnia) *

Which type of consultation are you seeking? *

Psychological TreatmentCoaching Psychological Assessment

Please tick the boxes for the assessments you are seeking:

Vocational Assessment and Career Guidance

FUNDING TYPE

Please tick if you will be financing your treatment through any of the following schemes: *

A Medicare Health Care Plan (Mental Health Care Plan, Eating Disorder Plan, Chronic Disease Management EPC)Private Health InsuranceInsurance (Compulsory Third Party [CTP], Workers Compensation)None of the above

Please upload your referral and health care plan

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Insurance Company Name

Insurance Company Claims Manager Name and Contact

Private Health Fund Name

Private Health Membership Number

SECTION 3: FEES AND REBATES

MEDICARE DETAILS

Medicare Card Number

Individual Reference Number (IRN)

Expiry Date (MM/YY)

FEE DETAILS AND AUTHORISATION

Fees may include:

Session fees

Session fees are payable prior to the Telehealth or in person consultations by any card bearing a Mastercard or Visa logo. 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 Pin Payments - a third party provider to securely and conveniently store your credit card for future transactions, in a secure and Payment Card Industry-compliant manner.

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 initial session we ask all clients to provide their payment method to us. 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. *

Client's Signature *

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Cardholder's Signature *

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Date *

SECTION 4: CLIENT CONSENT

I have read and understood and accept the Terms and Conditions (https://www.hallpsychology.com.au/terms-and-conditions.html) and give consent to Amanda Hall to liaise with the following people involved in my care about my psychological treatment. Please identify the people you consent for Amanda Hall to contact (it is a requirement of Medicare to provide written reports to your GP): *

General Practitioner Name *

Medical Specialist Name

Insurance Company Name

Insurance Claims Manager Name

Rehabilitation Company Name

Rehabilitation Coordinator Name

Physiotherapist Name

I understand and accept that personal information gathered by my psychologist will remain confidential and secure except when:

1. Failure to disclose the information would place you or another person at risk of harm,*

2. It is subpoenaed by a court,

3. My prior approval has been obtained to provide either a written report or to discuss the material with an external professional or agency.

*Psychologists are considered “mandatory reporters” and are required by law to report to the statutory regulatory body if they suspect (using their professional judgement and training), on reasonable grounds, that a child or young person is at risk of harm (i.e. physical, sexual or emotional abuse or neglect).

Client Consent for Use of AI Technology in Psychological Services

As part of providing high-quality psychological care, your clinician may use artificial intelligence (AI) tools, including NovoNote and Heidi, to support aspects of documentation and treatment planning. This document explains how such technologies may be used and seeks your consent.

1. Purpose of AI Use

The AI tools may assist in the following areas:

Transcribing clinical notes or summaries from sessions.
Generating draft reports (e.g., progress notes, letters, assessments).
Supporting treatment planning and formulations.
Organising and summarising information to support clinical decision-making.
Enhancing administrative efficiency to allow more time for clinical care to allow us to focus more on communication and your care during sessions, rather than being distracted by manual note-taking.

2. Confidentiality and Data Security

AI tools used by this practice (such as NovoNote and Heidi) are selected based on their compliance with relevant privacy and data protection laws, including the Australian Privacy Act 1988 and the APS Code of Ethics.
NovoNote and Heidi comply with the Australian Privacy Principles and is compliant with AHPRA and HIPAA standards. It adheres to industry encryption and security protocols. NovoNote and Heidi operate on a secure server in Australia and your data does not contribute to training AI models. For more detailed information on the security measures and protocols of NovoNote, please visit the security page: NovoPsych.com.au/NovoNote_Security
Only your clinician will have access to your information.Your dataprotection is our top priority.
Identifiable information is handled with care. All data shared with AI systems is de-identified or anonymised.
AI tools used in this practice do not make autonomous clinical decisions. All clinical interpretations, diagnoses, and treatment plans remain the responsibility of your treating psychologist.
As a healthcare provider, we keep notes of our contact with you to help us serve you better. Our AI note takers, NovoNote and Heidi, help by transcribing the session and then providing a summary of that session. Typically, the transcript of the session will be deleted and will not make up part of your patient file, while the summary is saved as part of your file.
Conversations are transcribed simultaneously while they happen, meaning no audiorecordings are ever stored. Only data will be collected that is essential for providing services.

3. Limits and Safeguards

AI-generated content (e.g., drafts or notes) is always reviewed and edited by your clinician before being added to your file.
No AI tools will be used for surveillance, behavioural prediction, or any purpose outside the scope of your psychological care.
Only data will be collected that is essential for providing services.
Notes that a clinician saves at the end of each appointment will be copied and added to your Electronic Health Record in your clinician’s secure Practice Management System, as standard.
You may ask at any time how your data is used and may revoke your consent at any point without affecting your access to psychological services.

4. Voluntary Consent

By signing this form, you acknowledge that:

You have read and understood this information.
You consent to the use of AI tools, including NovoNote, as described above to support your psychological care.

If you have concerns or wish to limit the scope of AI use in your care, please discuss this with your psychologist.

Client Consent for Research

I consent to Hall Psychology and Coaching using and sharing my de-identified and anonymous personal information and questionnaire results for research. I understand that I may withdraw my consent at any time although if my personal information has been used in a project or incorporated in a database it may not be possible to remove my personal information. I consent to Hall Psychology and Coaching using and sharing my personal information to contact me about participating in future research projects.

Client Consent for Marketing

I consent to receiving emails from Hall Psychology and Coaching with information about services, promotions, special offers, news and events.

Signature *

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Date *

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