Customer Registration

Customer Registration
Full Name *
Please enter both your first name and last name
Date of Birth *

Day Month Year
Gender *

Male Female Non binary
Medicare Card Number *
Please enter 10 digit Medicare card number Ex: 3501 80315 1
Medicare Card Reference Number
What's the number to the left of your name on the Medicare card? *
Medicare Card Expiry Details *
Mobile Primary *
Please enter your mobile number starting with 04
Secondary Number *
Please enter a secondary phone number
Email *
Address *

Street Address

Street Address Line 2

Suburb State

Postal Code
State *
Next of Kin Name *
Next of Kin Phone *
Case Worker/Representative
How did you find us?

Youtube Twitter GP Private Psychologist Google Search Public mental health service/Hospitals NGOs Other [Please state]
What devices you have access to?

Laptop Desktop Mobile Phone Tablet Other [Please state]
What device you most likely to access our service from?

Laptop Desktop Mobile Phone Tablet Other [Please state]
Other services of interest

Psychology Other [Please state]
Can we have your consent to contact you regarding other services that you have selected above?

Yes No
Do you have an NDIS package?

Yes No
Have you seen another psychiatrist in the past 12 months? *

Yes No
Have you seen another psychologist or counsellor, this year, using a mental health care plan? *

Yes No
Do you want to be added to the late cancellation list for your clinician?

Yes No
Can we get your consent to check your consultation history with Medicare? We may require this in order to check your entitlement for services provided *

Yes No
Please choose a date and time you will be available within the next two days to onboard with us via a Zoom call. *Details to be sent later *
For office use only

GP Provider Number
GP Name
GP Clinic

Clinic Name Address Fax Number Email

GP Clinic
Current GP
Client Status

Inactive - Joseph Inactive - Shalinda Inactive - Sowmya Inactive - Zorica Inactive - Sandy Blacklisted
Rural/Metro

Rural Metro
Have you informed the client about our Bulk bill clinical psychology service?

Yes No
Informed client of clinicians no shows & late cancellation policies

Yes No
Notes
Should be Empty:

Customer Registration

Medicare Card Reference Number