NEW CLIENT FORM

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Please complete the form below to assist us before your initial appointment.

Once you complete the form and press “Submit Form”, the form will be sent to us and emailed to you as an attachment.

If you cannot complete the online form below, please go to New Client Forms to download a pdf form that you can fill in, and either email it to us or bring it with you, to assist us with your initial appointment.

 
New Client Form

New Client Form

Type of Client Form

Confidentiality

Confidentiality is important in building a relationship with you and will be discussed early on in your session/s with us. This means that whatever you discuss in sessions with us remains private and will not be passed on to anyone else without your permission.

However, there are some exceptions to this:

  • When your, or someone else’s health or safety are seriously threatened, and the information will help them.
  • If your written consent has been obtained to share information to another person (e.g., family member, employer, doctor, or another agency).
  • If your case file is subpoenaed by court - we will let you know about the request.

To assist us in working with you, we will need to collect and record personal information from you that is relevant to your situation. While most of our information will be collected directly from you, we may need to speak to your doctor(s), allied health practitioners, case managers, family members, or others involved in your care with your permission. Your personal information will be recorded in a secure Paragon PsychConnect database not available to anyone outside of Paragon PsychConnect.

Client Details

Title
Address *
Address

Work or Vehicle Injury Claim (Compensable) Details

Type of Claim
Accepted Claim
Billing Postal Address
Billing Postal Address
Treating Doctor Address
Treating Doctor Address
Referral Attached
Maximum upload size: 2MB
Please load all relevant files for this Work or Vehicle Injury Claim

Private/Medicare Details

Private Health Insurance (Extras)
Centrelink (Job Seeker, Disability Support Pension, Aged Care Pension)
Medicare Mental Health Plan
PLEASE NOTE:  Concession rate is ONLY if you are in receipt of Centrelink payments (Aged Pension, New Start, Disability etc).  This will have been discussed with you at the time you made your appointment.
Maximum upload size: 2MB
Please load all relevant files for this Private/Medicare Referral

NDIS Details

To assist us in working with you, we will need to collect and record personal information from you that is relevant to your situation. While most of our information will be collected directly from you, we may need to speak to your Support Coordinator, any allied health practitioners, support workers and family members, or others involved in your care. Your personal information will be recorded in a secure Paragon PsychConnect database not available to anyone outside of the Paragon PsychConnect company.

Sometimes we may also have to provide files for a confidential review by the accrediting body (e.g., NDIA) to ensure that we are working within the national standards and frameworks.

We are bound by the Privacy Act 1988. If you would like to know more about how we collect and store your information, please contact Tony Wallace, General Manager (ua.moc.tcennochcyspnogarap@ynot).

Who is Responsible for Management of this Plan?
Who is Responsible for Coordination of this Plan?
Maximum upload size: 2MB
Please load all relevant files for this NDIS Referral

Release of Information Consent

All information is considered confidential and used solely for providing care and management of your case. We may need to contact some or all of the following people in regard to your recovery. You can remove this authority at any time.

I agree to Paragon PsychConnect communicating with the above individuals regarding my care.

Consent and Acknowledgement *

Consent and Acknowledgement *
Privacy Policy *

Subscriptions *

Did you know that Paragon PsychConnect email subscribers receive exclusive access to member only tools and services AND reduced rates for online and group programs?

PLUS we will provide you with a FREE hypnosis track when you subscribe.

It doesn’t cost anything to sign up and you can unsubscribe any time. We will never pass on your email address to anyone else.

Please select No if you do not wish to subscribe.

Subscribe to Paragon PsychConnect
Person With a Huge Tick and Thumb Up for Paragon PsychConnect Subscription

Payment and Cancellation Policy

We request 24 hours’ notice of cancellation of appointments. Failure to do so or DNA (non-attendance without letting us know) will incur a cancellation fee of 100% of the fee.

Work or Vehicle Injury Claim: This is not covered by your insurer and is payable by you.

Private/Medicare: This is not covered by your Private Health Insurer or Medicare and is payable by you.

Please ensure that you keep a record of your appointment and do not cancel only when you receive a reminder SMS or email. The reminder is just a courtesy.

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