Request a Mental Health Care Plan appointment

The purpose of this form is a once off yearly charge of $55 which allows to cover the cost of communicating with your Psychologist or other Healthcare professional.

Patient details

First Name *

Last Name *

DOB *

Phone Number *

Email Address

Residential Address *

Do you have a Medicare card? *

YesNo

Preferred Appointment date and time

Reason for appointment *

Preferred date and time

Is the appointment for you or your child? *

MyselfMy childOther/Guardian

Consent

In submitting the information contained in this form, I consent to the collection of personal information and Privacy Policy, confirm I have read and acknowledge the Billing Policy, and have read and understood the MHCP FAQs. *

How did you hear about us?

TalkedSocial MediaGoogleFamily/FriendHealthcare Professional

If eligible for Medicare, DVA or concessional billing do you give permission to bill? *

YesNo

If Bulk Billed, I assign my rights to the Healthcare professional who rendered the services. If eligible for a Mixed billed consultation a medicare rebate will be processed and deposited into your nominated bank account directly by Medicare. *

YesNo

Referral

Do you give consent to provide your MHTP to partner psychologist(Talked)?

Yes, please send my MHTP directly to Talked.No, I already have a preferred psychologist.I have not made a decision on my psychologist.

Message or Comment

Payment

A once off yearly charge of $55 which allows to cover the cost of communicating with your Psychologist or other Healthcare professional.

Please complete the following payment prior to submitting your form *

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