Patient Information Form

Please complete this patient information form and payment details and we will be in touch to confirm your details and book your appointment.

First Name(required)

Surname Name(required)

Gender(required)

Date of Birth(required)

Email(required)

Phone Number (required for Telehealth)(required)

Emergency Contact Name and Phone Number (or next of kin)(required)

Rebate

Please select relevant rebate method(required) Private Health Fund

Medicare Rebate (GP Mental Health Plan required)

Department of Veterans Affairs (DVA) and Open Arms Sponsorship

Date of Mental Health Plan (if applicable)

Doctor's Provider Number (on Mental Health Plan)

Referring Doctor's Name

Medicare Number(required)

Individual Reference Number (IRN) on Medicare Card (required)

Medicare Card Expiry Date (required)

DVA Card Number / Colour(required)

Would you prefer a Face to Face or Online appointment?

Select preferred assessment type:(required) Face-to-Face

Telehealth (Phone)

Zoom Video Conference

Skype Video Conference

Face Time Video Conference

If you are in crisis or danger, please DO NOT USE THIS SITE. Please call 000 on your phone.

Lvl 4, Suite 14-15 PARKRISE
3 Alison Street
Surfers Paradise, QLD 4217
Australia
E: hello.accesspsychology@gmail.com
Ph: 07 5592 4879

Monday – Thursday 9am – 4pm.
Call us to make an appointment,
or click here to send us your details and we will be in touch.