Adult Client Information & Consent Form




Psychology Consultation / Report (onsite/ phone/ skype)

Clinical Psychologist – per 1 Hour

Registered Psychologist – per 1 Hour




Speech Pathology Consultation / Report (onsite/ phone/ skype)

Speech Pathologist– per 1 Hour



Occupational Therapy Consultation / Report (on site/ phone/ skype)

Occupational Therapist - per 1 hour

Report - Comprehensive full report

Report- Summary of Results





Allied Health / Therapy Assistant - per 1 hour


Psycho-educational Assessment - General IQ and Adaptive Functioning/Academic Achievement

Clinical/ Registered Psychologist (3 hours)

Provisional Psychologist (3 hours)




Team Autism Diagnostic Assessment – With both a Speech Pathologist & Psychologist (3 hours)


Non-attendance/Cancellation Fee

 <24 hours notice, 50% of you consult fee will be charged



Please Note:

  • Payment is expected in full at the time of consultation. We accept Cash, Cheque, EFTPOS, MasterCard, Money Order + Visa.
  • Reports will not be released until payment is received.
  • All fees at Headstart are set lower than the Australian Psychological Society's recommended rate of $251 per hour.
  • Medicare rebates do not currently apply for Psych-Educational assessments.




Psychology Consultation / Report (onsite/ phone/ skype)

Clinical Psychologist – per 1 Hour
Registered Psychologist – per 1 Hour




Speech Pathology Consultation / Report (onsite/ phone/ skype) - per 1 hour


Occupational Therapy Consultation / Report (onsite / phone / skype)  per 1 hour


Allied Health / Therapy Assistant - per 1 hour


Travel Fees are based on time and are calculated as per NDIS guidelines


Non-attendance/Cancellation Fee

If cancelled less than 24 hours notice, 90% of you consult fee will be charged



Please Note:

  • A copy of the client's NDIS plan is requested so sessions can be focused on the goals outlined in the NDIS plan.
  • NDIA review the fee schedule annually and fees may be subject to change as of the 1st of July.


Medicare rebates may apply with an appropriate referral from a GP. Please book a long consultation with a GP prior to the initial appointment at Headstart. The GP will establish if the client qualifies for a Mental Health Care Plan (Psychologist) or Enhanced Primary Care Plan (Psychologist/ Speech Pathologist/ OT) under the Government's Better Access to Mental Health Care Scheme. It is the GP's discretion whether these referrals are appropriate for each client.  Please note some clients may not be eligible for certain referrals.  Referrals from Paediatricians and Psychiatrists for children under 13, with a recognised diagnosis of Autism Spectrum Disorder, can also attract a Medicare rebate.  Further information can be found on the Medicare Australia website


A majority of Private Health Insurers provide a rebate for Psychological / Speech Pathology and Occupational Therapy Services. It is the responsibility of the individual clients/carers/parents to contact the individual Private Health Provider to determine their rebates.
Please note: you are unable to claim a rebate from both Medicare AND Private Health, and can only choose one rebate pathway.

Client Information & Consent Form


Please submit one week prior to your appointment

NDIS funding?

Training/ Professional Development


Headstart Intervention Services prides itself on professional development and training.  As such at times we have Psychologists/ Trainees / Higher degree students sitting in to observe. At times additional testing may be required that is outside that included in the consult.  For example, a diagnostic would not typically include a cognitive assessment but with the support of a Provisional Psychologist this may be completed. We understand you may not wish for this to occur. Could you therefore please complete the following:     

From time to time clinicians may need assistance or support from colleagues within Headstart.

This information would only be provided if you were to make appointments with a clinician in addition or in preferences to the initial consultant.

Personal Information Collection & Consent Statement

We collect information about you for the primary purpose of providing quality supports and services. If you do not provide this information, we may be unable to full provide these services. This information will also be used for:

  • Administrative purposes for running our service
  • Invoicing you directly or through NDIS, or other agency if required
  • disclosure of information to health professionals to ensure high quality health care for you if needed
  • disclosure of information to the NDIA, the NDIS Quality and Safeguards Commission, or other government agencies if needed.
  • disclosure to other providers in order to provide appropriate services

We may disclose information regarding you to other service providers or health professionals only with your consent.

We do not disclose your personal information to overseas recipients.

Specific service or product information as deemed suitable for you, may be forwarded to you by us, unless you instruct us not to forward this type of information.

We have a privacy policy that is available on request. That policy provides guidelines on the collect, use and disclosure and security of your information.

File information is stored securely and access only by our workers. Headstart takes all reasonable steps to ensure that information collected about you is accurate, complete and up-to-date.

Headstart gains information and direction from ISG (Information Sharing Guidelines and The Privacy Act 1988

Any concerns you may have about this statement or the information we store about you can be directed to:

The Practice Manager


Via email:

or by phone:
(08) 8373 4531

or by mail:
Po Box 58
Goodwood SA  5034


Do you give consent for the information obtained at Headstart to be accessed for research purposes. It would be provided in a deidentified format. You will not be individually identified. You can withdraw this consent at any time. My response to this (either yes or no), will not affect my services at Headstart in any way. The information will only be accessed by persons undertaking research with approval from their relevant ethics committees.

Do you give consent for the information obtained at Headstart to be accessed for research purposes?
Any queries can be directed to your consultant

Additional Information


“The Consent to Medical Treatment and Palliative Care Act 1995 (SA) prescribes that an individual of 16 years of age or over can consent to medical and dental treatment 'as validly and effectively as an adult”. K. Bowles. (2003). Age of consent to medical treatment. Retrieved 1st July 2007, from  It is therefore required that the parent or legal guardian of a minor agrees to the terms and conditions of receiving services at Headstart Intervention Service on behalf of children under the age of 16 years.


State law indicates that one parent is to be informed of children less than 16 years attending a Psychologist. As such, it is important that the Consultant is made aware of any custody or legal arrangements associated with the child. Please bring along to the initial appointment documentation of any custody arrangements. If there are any current or impending legal disputes in relation to the custody of the child it is the responsibility of the parent in attendance to inform the consultant. Services may be denied if such information is withheld.

Should a non-attending parent require further information they may make an appointment to discuss the care of the child.  Such appointments will not involve any communication about the other parent.  The focus will be on the care provided to the child.  No phone calls unless pre-arranged will be accepted.

A visit summary will consist of a brief recount of what was undertaken during the session.  This can be requested by either parent and supplied via email to the non-attending parent.  Request for summaries can be made at the front office or emailing the clinician directly.  A small fee will be charged.

If we feel any of the points outlined in this confirmation pack become an issue at the practice and/or compromising child care, we have the right to discharge the family from treatment at Headstart.


All consultants at Headstart will safeguard the confidentiality of the information obtained during the provision of services, including taking reasonable steps to maintain client confidentiality once leaving the work place or ceasing psychological, speech pathology or occupational services. Legal and organisational considerations will be made in regard to the collection, recording, accessing, storage, dissemination and disposal of information. Certain circumstances may require the disclosure of confidential information. Only that information which is necessary will be provided. Confidential information will only be disclosed:

  • With the consent of the relevant client or a person with the legal authority to act on behalf of the client;
  • Where there is a legal obligation to do so;
  • If there is an immediate and specified risk of harm to an identifiable person/s that can be averted only by   disclosing this information; or           
  • When consulting colleagues, or in the course of supervision or professional training, provided the consultant              conceals the identity of clients and associated parties involved; or obtains the clients consent
  • Your prior approval has been given to provide a written report or another professional or agency, or to discuss the material with another person.

Information adapted from: The Australian Psychological Society Code of Ethics / Speech Pathology Australia Code of Ethics. All clinicians from Headstart are required to adhere to these professional bodies including their code of ethics and their client care requirements.


Headstart value ongoing feedback and appreciate being made aware of any complaints or compliments that a client may have. Headstart have a feedback and complaint management system in place to support this process.

  • Speak to the client's clinician or the admin team to share feedback or complaint
  • Email feedback or complaint to clinician directly or forward to
  • Post feedback or complaint to Headstart Po Box 58, Goodwood SA 5034   attn: Practice Manager

NDIS participants are also able to make contact with NDIS Quality and Safeguard Commission: 1800 035 544


I, (client, parent, legal guardian) have read the enclosed information regarding Headstart Consultation Fees/ Payment Information (2019) & NDIS fee schedule , Medicare Rebates, Private Health Rebates, Personal Information Collection & Consent Statement, Additional Information including: Minors, Custody & Divorce, Privacy and Confidentiality, Feedback complaints and disputes which has been provided to me in this Confirmation Pack. I agree to these terms and conditions and give consent for Headstart to provide services to that person/s listed on the client information form. I understand that if an appointment made is cancelled with less than 24 hours' notice or not attended, that a cancellation fee of either 50% (Private Clients) or 90% (NDIS Participants) will apply. I also understand that appropriate Medicare referrals and rebates do not fall under the responsibilities of Headstart.