General Mental Health - Registration & Consent

This form is for new clients of General Mental Health, the private psychiatry and psychology service of March Ahead. Please complete it when our intake team sends you the link, before your first appointment. It takes about 15 minutes.

Our service is for adults aged 18 and over. If you are completing this form on behalf of an adult client, please answer the questions about them, with their knowledge.

If you are a veteran seeking DVA-funded care, please contact our team before completing this form. DVA-funded care is provided through our Veteran Mental Health service.

Your privacy. We collect your personal and health information to assess and treat you, to contact you about your care and appointments, to issue invoices and lodge Medicare claims on your behalf, and to correspond with your GP and referring practitioner. Your information is stored securely and handled in accordance with the Privacy Act 1988 (Cth) and the Australian Privacy Principles. Our privacy policy explains how you can access or correct your information, or make a complaint.

Confidentiality. We keep your information confidential. We share it only with your consent (for example, letters to your GP or referring practitioner), where the law requires it (for example, a court subpoena), or where it is necessary to lessen or prevent a serious threat to the life, health or safety of you or another person.

Emergency contact. We may contact your nominated emergency contact if we cannot reach you and it is reasonably necessary, for example in an urgent clinical situation. We share only the minimum information needed.

March Ahead is not an emergency service. If you need urgent help, call 000, or Lifeline on 13 11 14.

About you

Who is completing this form? *

I am the client, completing this form for myselfI am completing this form on behalf of an adult client, as their guardian, carer or support person

First name *

Last name *

Date of birth *

Email address *

Mobile phone number *

Home address *

Street address *

City *

State *

Postcode *

Occupation

Medicare and referral

Medicare card number

Individual reference number (IRN), the number beside your name on your Medicare card

Medicare card expiry (MM/YYYY)

Do you have a referral or a mental health treatment plan? You need one for a Medicare rebate. Without one, you can still be seen privately at the full fee. *

Yes, a referral from my GP (for psychiatry)Yes, a referral from a psychiatrist or another specialistYes, a mental health treatment plan from my GP (for psychology)Not yet

Upload your referral letter or mental health treatment plan, if you have one

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Your GP and emergency contact

Your GP's name and practice (write None if you do not have a GP)

Referring doctor, if different from your GP (name and practice)

Emergency contact name *

Emergency contact phone number *

Consents

I consent to psychiatric and psychological assessment and treatment through March Ahead's General Mental Health service, by video, phone or in person. I understand that I can ask questions at any time, decline any part of the treatment offered, and withdraw my consent at any time.

For video and phone appointments, I will tell my clinician where I am at the start of each appointment and make sure I am somewhere private. If a video connection fails, my clinician may continue the appointment by phone. In an urgent or emergency situation, my clinician may contact emergency services and my emergency contact.

*

I consent to my treating clinician writing to my GP and referring practitioner about my assessment and care, including a letter after my first appointment. If you do not want this, leave this box unticked and tell our intake team.

I agree to March Ahead contacting me by email about my appointments, care and invoices. I understand that email may not be a fully secure way to communicate.

*

I agree to receive SMS messages from March Ahead to confirm my appointments and remind me of them.

Fees and payment

How will you pay for your appointments? *

Card: I consent to my card details being collected when my appointment is booked and stored securely by the practice's payment provider. I authorise March Ahead to charge this card for my appointment fees after each consultation, and for any cancellation or non-attendance fee under the terms below. I can withdraw this consent at any time by contacting the practice.Bank transfer: I have arranged with the intake team to pay by bank transfer. I will pay each invoice in full on the day of the consultation, and pay any cancellation or non-attendance fee under the terms below the same way.

I have read and agree to the following about fees and payment.

Fees. The fee for each appointment is confirmed with me in writing before I book. Fees are reviewed from time to time, and I will be told of any change before it applies to me.

Payment. If I pay by card, my card is verified when the appointment is booked and charged the full fee after each consultation. If I have arranged to pay by bank transfer, I pay each invoice in full on the day of the consultation.

Medicare rebates. If I have a valid referral, or a mental health treatment plan for psychology, the practice lodges my Medicare claim once the invoice is paid, and Medicare pays the rebate into the bank account I have registered with Medicare. The difference between the fee and the rebate is my out-of-pocket cost. Without a valid referral or plan, and for some phone appointments, no Medicare rebate applies and I pay the full fee.

Cancellations. If I cancel or reschedule with at least two full business days' notice, no fee applies. With less notice, 50% of the fee applies. If I cancel with less than 24 hours' notice or do not attend, the full fee applies. No fee is charged if the appointment time can be offered to someone else. Cancellation fees cannot be claimed from Medicare.

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Sign and submit

Date

Signature (the client, or the person completing this form on their behalf) *

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Thank you. Once you submit this form, our intake team will review it and contact you to confirm your appointment and its fee in writing.

March Ahead is not an emergency service. If you need urgent help, call 000, or Lifeline on 13 11 14.

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