Documentation Request from Treating Psychologist

Please complete and submit this form if your client has requested a document in session. Our CS team will provide a quote and invoice for payment, if applicable. Our team will then advise you when payment has been received so you can commence working on the document. CS will upload a copy of the form to the client file for record keeping purposes.

What is the client's full name: *

Is this a Bulk Billed client? *

YesNo

Treating Psychologist name: *

Document Type *

Form to fillClient file requestAssessmentReportLetterOther

Date client requires this document by:We cannot guarantee the completion by this date however your psychologist will work toward this.

Supporting documents/forms to attach?

YesNo

Upload any supporting documents (doc, pdf, jpeg)

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Purpose of, and required information for this document: *Please provide all relevant details

Is the client a minor? (Under 18) *

YesNo

Do you have consent from a parent/guardian? *

YesNo

The CS team will send a minor consent form to the client's parent/guardian. Once received, the team will upload this to the client file for you to review and complete the request.

Name and contact details of parties sharing information: *Please provide name, address, phone number and email of any contact parties.

Is there a charge for this documentation request? *

YesNo

Please indicate the time spent for invoicing purposes *

15 minutes30 minutes45 minutes60 minutes90 minutes120 minutesOther

If longer than 120 minutes please indicate the total time spent below: *

Acknowledgement of Submission *

Yes

I acknowledge that all details filled is correct and has been discussed in sessions with the client's consent.

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