Initial Appointment Enquiry

Please select one of the clinic location/service you have been referred to or are inquiring about *

VCPS Psychology & PsychiatryChinwag (Australia wide - Telehealth phone & video sessions)I have a referral to Bangalow Clinical Psychology (our NSW Partner clinic)

What type of service are you seeking: *

Will there be a third party funding the assessment for the client? *

YesNo

Please include organisation name, address, contact person (including name, email and phone) of who the invoice should be addressed and sent to: *

Please specify why the main purpose/s for Neuropsychology assessment: *

Have you had any previous neuropsychology assessment? (If so, you will need to provide a copy of the report prior to the assessment): *

YesNo

Please provide as much information has possible regarding your Medical/Psychological History: *

Do you have any vision/hearing impariments? *

YesNo

Do you have any mobility issues? *

YesNo

Has the client had any previous neuropsychology assessments completed? (If so, please provide a copy of these assessments prior): *

YesNo

Please provide as much information has possible regarding the clients Medical/Psychological History:

Does the client have any vision/hearing impairments: *

YesNo

Does the client have any mobility issues? *

YesNo

Are there any behavioural symptoms noted with the client: *

Are any issues noted with alcohol/substance use with the client: *

YesNo

Please provide any other relevant detail on previous history or assessments: *

Please upload any other relevant details on previous assessments completed for the client

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Client's Full Name (as per Medicare Card/ID) *

Parent/Guardian's Name *

Partner's Name *

Client's Date of Birth *

Contact Number *

Email Address *

How did you hear about VCPS? *

Online searchWord of Mouth GPMy employer

Referrer Name and Relationship to you

Please list your General Practitioner Name and clinic details below

Organisation Name and Address

If you have been recommended to a specific VCPS practitioner, please add their name here

If you have a copy of a referral letter and/or any other supporting documents, please upload them here

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You need a valid GP referral to be eligible for a Medicare Rebate. Not having a referral may also impact your ability to claim services from both Medicare and Private Health Insurers.

Psychiatry Referral Copy *

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You need a valid GP referral prior to book any psychiatry appointment. Please include copy of your referral here for us to review.

Is there any other information you would like to tell us to help you make an appointment, including any preference for the type of practitioner you would like to see:

Please select your preferred time for an appointment:

AM PMAny available time

I confirm that above information I have provided is true, complete and accurate *

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