INTAKE FORM
Please provide the information and answer the questions to the best of your ability. Take your time and
really think through the answers. All information you provide on this form is protected as confidential information.
Please fill the online form below or download the PDF version and send us later before the sessions.
Please do not hesitate to contact with me if you have any questions.
Download the necessary form(s), print them out and fill in the required information.
Please click here for the intake form
Therapy Expenses
If you have a referral from your GP such as a Mental Health care plan, the sessions will be bulk bill. Your GP practice will scan you Mental Health Care plan to FreeFlow mental health and wellbeing email:
rosevp123@protonmail.com
or mail to:
Ina Van Puymbroeck
P.O.Box 1542 Kersbrook 5231
Once I receive your MHCP , I will call you for an Appointment, or you can call me on 0403 409 772.
The Medicare plan allows for a total of six sessions initially. Returning to your GP for a review may result in a further four sessions if he/she considers it appropriate. Upon a second GP review, a further ten sessions may be granted. A maximum of twenty session rebates can be received in a calendar year (one can only access a maximum of 20 psychology sessions under a mental health care plan per year).
The Chronic disease management plan/team care arrangement under Medicare
Those managing a chronic or complex medical illness (a chronic medical condition lasting 6 months or more) may be eligible to receive a referral from GP for a rebate. Up to 5 visits with an allied health profession is allowed per year. Eligible medical conditions include Asthma, Cancer, Cardiovascular illness, Diabetes, Musculoskeletal conditions, or Stroke. Please note, sessions are likely to be shorter than 60 minutes.
If you do not have a Mental Health Care Plan , the first session cost $150 and follow up session is 125. Most health insurance will reimburse. Once I receive your payment we will schedule the sessions and you receive your receipt so you can claim back your session with your health insurance.
If you book and pay for 5 session in advance the total cost is $575.
My bank details are H.J.Van Puymbroeck
ANZ bank
Account number
FreeFlow Mental Health and Wellbeing
Cancellations
A minimum of 24 hours notice is required. If no notice is given, a fee may be incurred.