PMCC “Let’s Talk” TeleMediation Registration Form


Client Registration Form

 

CLIENT DETAILS

Full Name: _______________________________________________________________________________________

Address: _________________________________________________________________________________________

Date of Birth: __________________

Telephone:

(m) __________________________ (h) ___________________________ (w) __________________________

Email: _________________________________________________________________________________________

Emergency contact:

Name: ______________________________

Phone: ______________________________

Relationship to you:___________________

 

REFERRAL DETAILS

Referrer’s Details:

_________________________________________________________________________________________

How did you hear about our “Let’s Talk” TeleMediation & Counselling Service?

_________________________________________________________________________________________

 

PRIVACY STATEMENT

  • In signing this form, you consent to the collection of personal and referral details and to the storage of these details in the Perth Mediation & Counselling Centre database. This information will not be shared with any party without your consent.
  • Your mediation and/or counselling practitioner will prepare, store and maintain your clinical records. In doing so, he or she must comply with all relevant privacy laws and follow strict professional codes of conduct. We recommend you speak with your practitioner about privacy, confidentiality and any other professionals who may be contacted about your care.


PAYMENT

You agree to pay Perth Mediation & Counselling Centre for your agreed “Let’s Talk” TeleMediation and Counselling Sessions at a cost of $50 per hour + GST prior to your session via direct bank transfer or PAYPAL.

You acknowledge your mediation and counselling practitioner cannot proceed with the Teleservice consultation until payment is received and that if another party is invited to participate in the Teleservice consultation with you that they may be upset that you have reneged on the agreed terms of the Teleservice consultation.

Signed: __________________________________________ Date: ______________________________


CANCELLATION POLICY

Practitioners participating in the “Let’s Talk” TeleMediation & Counselling Service have a contract with the Perth Mediation & Counselling Centre for the services they provide to you. While unexpected events may occur from time to time, we do ask that you try to provide at least 48 hours’ notice if you need to cancel or reschedule your appointment. Your practitioner will receive no remuneration if you do not attend a booked appointment.

If two or more appointments are missed or cancelled within 48 hours of a booked appointment,

I agree to pay Perth Mediation & Counselling Centre a fee of $50 + GST.

Signed: __________________________________________ Date: ____________________


Please note:
Perth Mediation & Counselling Centre Pty Ltd and any of its subsidiary companies is not liable for any consultative services you may receive through the “Let’s Talk” TeleMediation & Counselling service.