Patient Details

Contact Information

Emergency Contact Details

Do you identify as Aboriginal or Torres Strait Islander?*

Please select your gender identity*

Referral/Payment Details

Please select from the below based on how you were referred to our services

Session Location

Telehealth links are included in your text message reminders. You will receive this link before your appointment which will allow you to see your psychologist within your internet browser via MS Teams. The link will automatically guide you, however if you have any problems please do not hesitate to contact our friendly administration team.

Payment Policy

Axis strives to ensure a clear understanding of the financial responsibility with respect to services that we provide. These policies apply to all clients accessing psychology services. Please select below categories to determine your responsibilities regarding payment.

NDIS

Plan-manged: An invoice will be sent to your plan manager the first Monday following your appointment. We expect reconciliation of plan-managed accounts within 14 days. If payment is not received in this time we may request you follow up with your plan manager.

Self-managed: An invoice will be sent to you the first Monday following your appointment. We expect reconciliation of this invoice prior to your next appointment. You also have the option to pay upfront via credit card of Eftpos on the day – but will need to request this method of payment.

Medicare Rebate

The cost of your treatment will have been explained to you. Please be advised that we are not a Bulk Billing practice, and you will be charged the full consultation fee on the day of your appointment. Where possible, we will process your Medicare rebate for you and will give you details to process the payment if not. If you have any questions about the cost of treatment, please contact our friendly administration team. Payment is made on the day of the appointment either via EFTPOS in the clinic or via credit card over the phone or with your psychologist.

Please inform your psychologist or admin staff if you have already used some of your Medicare funded sessions. Please also note that Medicare rebates are not able to be used while inpatient in hospital as per Medicare policy.

Private Health

The cost of your treatment will have been explained to you. You will need to pay the session cost on the day of your appointment. You will receive a receipt to claim for private health. Axis is unable to process private health rebates nor guarantee eligibility. Please check with your health insurance provider prior to your appointment to deem your eligibility and rebate amount.

If you have any questions about the cost of treatment, please contact our friendly administration team. Payment is made on the day of the appointment either via EFTPOS in the clinic or via credit card over the phone or with your psychologist.

Insured

An invoice will be sent to your insurer the first Monday following your appointment. We expect reconciliation in 14 days, and if this does no occur we will contact your insurer and may suspend treatment until these payments are made.

Workplace Funded Sessions

An invoice will be sent to your workplace the first Monday following your appointment. We expect reconciliation in 14 days, and if this does not occur we will contact your workplace and may suspend treatment until these payments are made. This is incredibly rare as we have a reliable working relationship with your workplace.

Other

The cost of your treatment will have been explained to you. If you have any questions about the cost of treatment, please contact our friendly administration team. Payment is made on the day of the appointment either via eftpos in the clinic or via credit card over the phone or with your psychologist.

Please click below when you have read and understood the relevant payment policy*

Cancellation Policy

Your appointment time has been reserved especially for you to provide you with psychological support. We appreciate your understanding that late cancellations/non-attendance occupies time that could be used to help someone else.

If you need to cancel or postpone an appointment, you need to provide at least 24 hours’ notice.

• If you provide at least 24 hours’ notice of cancelling or postponing your appointment, we will not charge a cancellation fee under this policy.
• If you provide less than 24 hours’ notice before cancelling or postponing your appointment, a cancellation fee equal to 50% of the full rate of your session will be charged.
• If you are a ‘no show’ at the start time of your scheduled appointment and without providing any prior notice, a cancellation fee equal to 50% scheduled service will be charged.

You will be charged applicable cancellation fees out of pocket regardless of your funding model should you not provide adequate notice. Payment is made on the day of the missed appointment either via eftpos in the clinic or via credit card over the phone or with your psychologist.

Axis has the right to refuse services if there are any outstanding balances on your account. Further sessions will be suspended or cancelled until any outstanding amounts have been paid. Axis will provide you with written correspondence regarding these issues if they pertain to you.

Our cancellation fees have been calculated with reference to the reasonable costs incurred by us as a result of the cancellation, and the likelihood that we will be able to re-book the cancelled booking.

In accordance with this policy and to the extent permitted by applicable law, you authorise Axis to charge any credit card you have authorised us to keep on file for the relevant cancellation fee through our third party payment service provider Square AU PTY Ltd ACN 167 106 176. You will receive a receipt for each charge made and you will be notified prior to any fees being charged.

By clicking here, you acknowledge that you have read, understood and agreed to our cancellation policy.*

Treatment Policy

We have a commitment to you to provide evidenced-based treatments, to care for you with empathy compassion and respect.

Your commitment is to be open, honest and to engage in the process as best as possible.

We will dedicate 50mins per session of face to face, the sessions are booked on the hour to account for administration and planning time between sessions.

We will help to keep track of how many sessions you have available and how many you have used, please don’t hesitate to clarify if you are unsure of how many are included in your referral.

By clicking here please acknowledge that you have read and understood our treatment policy*

Additional Information

Have you seen a psychologist before?

Privacy Collection Statement

Axis Rehabilitation At Work Pty Ltd ACN 633 631 295 collects the personal information provided by you in this form and during any sessions with us in order to assess the services required and provide you or someone else with the services and information you’re seeking. If you choose not to provide us with the information, or it’s incomplete or inaccurate, we may not be able to assess the services required or provide you or someone else with the services and information you’re seeking. If you have filled out this form about another person, you confirm that you have that person’s consent to fill out this form and disclose their Personal Information to us. We may disclose the information to third parties involved in your treatment and rehabilitation including your treating doctor or specialist, allied health therapists, employer, or injury management stakeholders for the primary purposes of providing quality assessment, diagnosis, treatment, and facilitation of a successful rehabilitation outcome. We will never disclose your Sensitive Information to your employer for the purpose of facilitating litigation, court proceedings or similar, unless we have your express consent. We may also disclose the information to our employees, contractors, and third parties who assist us in providing our services and operating our business, or as otherwise required or authorised by law. These third parties may be located outside Australia, in countries such as the USA. Further information about the third parties we disclose to can be found in our privacy policy published on our website (located here). Our privacy policy also contains further information about how we use your information, how you may seek access and correction of your information, and how you may make a complaint about a breach of privacy.

You can contact us about privacy matters by:
Email: info@helloaxis.com.au
Post: PO Box 10193, Adelaide Street, Brisbane QLD 4000
Phone: 1300 196 393

Signature that you have read and understood the relevant policies*