Appointment Request Form This form must only be completed with the informed consent of the client being referred for psychological consultation. It is advised that all parties be familiar with The Humanitarian’s Privacy and Service Terms & Conditions before proceeding. View Charter of Service View Privacy Policy View Terms and Conditions of Service View Terms and Conditions of Website Please use this form for requesting consultation for the purpose of: Pre-deployment consultation (briefing) Post-deployment consultation (debriefing) Counselling Coaching Psychotherapy Complete securely* online * information provided online is SSL encrypted in transmission. Name of person (attendee) requiring the appointment / consultation*Is the attendee an Australian citizen?*YesNoEmail address of attendee* Mobile /phone of attendee*Psychological service required* Pre-deployment consultation (individual) Pre-deployment consultation (group) Counselling consultation Post-deployment consultation (individual) Post-deployment consultation (group) Coaching consultation Psychotherapy session Anticipated number of sessions*12-4>4Limit of time / no. of hours in total over multiple sessions*Time required for the first session*75 minutes1.5 hours2 hours2.5 hoursNot specified / to be determinedDates required (range or days)*Preferred time/s of appointment*Consultation modalityIn person@ Level 1, 225-245 Drummond Street, Carlton, (Melbourne, Victoria, Australia)By skypeIf a Skype consultation is required, time difference between Melbourne and country of placementAttendee's Skype addressProfession / role of attendee*Organization*Country of assignment (if applicable)Duration of assignment (if applicable)Start and end dates of assignment (if applicable)Prior experience of person/countries lived in or worked in overseasDesired outcomes of the consultation:Any known risk factors, vulnerabilities, specific incidents or information of which the psychologist should be aware?(Note that this information will be openly discussed in the session)Any mobility, language requirements or other special needsIs any feedback required from the session? In what format?*(Note that if feedback is required, this will be shared with the attendee prior to disclosure)YesNoN/AOther comments, information or questions that will assist the service?Who is paying the fees of this service?*OrganizationIndividualExpiry date of authorization of service request**If this service is being requested and paid for by an Australian individual, do you have a Mental Health Plan completed by an Australian GP?YesNoN/AIf this service is being requested and paid for by an organization, name, role, email address and contact number of person authorizing this service?Contact email and phone number for administration purposes only*Name and postal address to appear on Tax Invoice*Person to whom Tax Invoice is to be directed*Email address for sending Tax Invoice*Reference number or Purchase Order details to appear on Tax Invoice*Organization*If you would like to receive a copy of the submitted form via email, please submit your email addressPlease nominate a 4 digit secure code which you will need to apply to open the completed form when it is emailed back to youPRICES ARE QUOTED IN AUSTRALIAN DOLLARS Note that 10% GST will be charged to organizations requesting and paying for a psychological service on behalf of the attendee. A 50% cancellation fee will be applied for appointments not attended or cancelled within 24 hours of service. By submitting this form, you are authorizing the service to proceed with an understanding of the Charter of Service, Privacy Policies and Terms and Conditions under which The Humanitarian operates. Both the attendee and the person organizing the appointment will be emailed with appointment options times as soon as possible and within 3 working days of receiving this form. In the event of a technical hitch, if you do not receive contact from The Humanitarian to discuss or to arrange a convenient appointment time within 3 days, please contact psychologist, Amanda Allan directly by email: amanda@thehumanitarian.com.au or phone +61 409 007 629. Click to submit form if you have read the Charter of Service, Privacy Policies and Terms and Conditions by which this service is conducted. Any queries, please email psy@thehumanitarian.com.au
