Client details
First name
Surname
Date of birth
Details of person whose credit card is being charged
Email
Mobile number
Inner Melbourne Clinical Psychology’s cancellation and rescheduling policy I am aware if an appointment is changed or rescheduled within 48 hours, unless there is an emergency I will be charged the full fee for this session. Please note that Medicare and private health insurance do not provide rebates for cancelled or unattended appointments.
Arrangements for payments, invoicing and rebates
I give permission for payments for the client's sessions to be deducted from my credit card, details of which will be given to an Inner Melbourne Clinical Psychology Support Team member over the phone.
By ticking this box, I'm verifying all details and statements made in this form are true and correct.