Form 027

Confidential

Have you received an email from Mind & Brain offering you an initial appointment?

Yes

No

Before registering you need to upload your referral and wait for up to 5 business days to receive a reply confirming if we are able to offer an appointment. Please do not attempt to register before an initial appointment is offered.

Name(Required)

First Last

Address(Required)

Street Address Suburb State Postcode

Phone(Required)

Email(Required)

Medicare Card(Required)

Individual(Required)

Valid To(Required)

Date of Birth(Required)

Next of Kin or Emergency Contact(Required)

First Last

Contact Phone(Required)

Relationship to Patient(Required)

Gender at Birth(Required)

Male	Female

Gender Identity (optional)

Registration Options(Required)

	Yes	No
I would like to receive Appointment Reminders by SMS
I would like to be added to the cancellation list
I would like a copy of my registration details emailed to me after I submit the form

Your registration details will be sent by email in a password protected document.

Enter your birthday in the format DD/MM/YYYY to open the document.

ADHD Assessment and Treatment Process
Effective 1 August 2024

ADHD Assessment Process

Step 1 - Meeting with our Psychologist (at the clinic):

Firstly, we will offer you an intake appointment with our psychologist for history taking. This appointment will take about one to one and a half hours. Tests/rating scales will be sent after your appointment by email and we will appreciate if you can complete all tests at least three days before your next appointment.

If you have any school reports available, please bring them to the appointment. We encourage reading your school reports in advance and prepare to show teachers comments suggestive of ADHD or other difficulties. If there are no comments suggestive of ADHD, still bring your reports for review. We also understand that some people have no access to their school reports, and it should not affect your assessment.

Step 2 – Assessment with our Psychiatrist (at the clinic):

Collateral information is required for a diagnosis, and we encourage you to bring a family member or someone who knows you well to this appointment. We understand that in some cases it might be difficult or not possible. Please advise us in advance if you cannot bring a family member and we can try to arrange an alternative way to obtain collateral information.

Our psychiatrist will review intake notes, results of tests/rating scales; take additional history, screen for mental health comorbidities/physical problems and conduct an ADHD focused clinical interview.

If treatment with ADHD medication is indicated but cardio-vascular risk factors are identified, our psychiatrist will organise a referral for an ECG (electrocardiogram). Some patients may require further medical input (GP, cardiologist or other specialists) before starting treatment with ADHD medication.

After this appointment, we will send a referral for an observed Urine Drug Test (UDT) to your phone by SMS and the test is expected be completed within 3 days.

UDT can be arranged at Clinipath Pathology. Please ensure you have Photo ID and Medicare card for the test. Please check online (Clinipath website) what office is open for the drug testing before attending as not all labs are providing this service.

Step 3 – Second appointment with our psychiatrist (at the clinic):

Discussing diagnosis, management plan, and starting treatment if treatment is indicated (appointment with a psychiatrist will take up to 30 - 45 minutes at the clinic).

Step 4 - Follow up Appointments:

After stimulant treatment commencement, regular follow-up appointments would be required during the initial stage of treatment (after 1 or 3 months, and then on a 6-monthly basis). The frequency of appointments varies depending on your presentation and complexity.

Medicare rebates apply to all consultations with our psychiatrist.

ADHD Treatment

Stimulant Treatment:

Stimulants can be contraindicated for some physical and psychiatric conditions, and alternative types of nonstimulant or non-pharmacological treatment may need to be considered.

Advice about your ADHD treatment/management will be provided during your appointment with our psychiatrist.

All stimulant prescribing is regulated according to the Schedule 8 Medicines Prescribing Code. You can read more about stimulant prescribing by accessing the Code online as it is accessible to the public.

https://www.health.wa.gov.au/Articles/N_R/Opioids-benzodiazepines-and-other-S8-medicines

Authorization by the Department will be required in case of comorbidities such as:

Any history of stimulant-induced psychosis (see Part 1 of this Code);
Any history of psychosis or bipolar disorder;
Any history of substance abuse, diversion, or misuse of drugs of addiction or S9 substances within the previous five years;
A record of drug dependence or oversupply (see Part 1 of this Code);
A current participant in a Community Program for Opioid Pharmacotherapy.

If treatment with stimulants is indicated, you will be expected to participate in urine drug testing (annually or as per the instruction of the psychiatrist) as per WA Department of Health requirements.

Terms and Conditions(Required)

I agree with the terms and conditions and have read and understood the ADHD Assessment Process and would like to proceed with my initial consultation for ADHD assessment.

I accept the Terms and Conditions

Financial Disclosure
Effective 3 September 2024

Mind and Brain is a private medical practice and aims to provide optimal care for each individual patient. Occasionally our practice fees are adjusted to reflect changes in Medicare rebates, practice costs, wages, and new items. From 3 September 2024 Practice Fees are as below.

Description	Fee	Rebate	Gap

New ADHD assessment (three appointments)	1,200.00	386.75	813.25
Intake appointment	250.00	-	250.00
Initial psychiatrist appointment	600.00	255.90	344.10
Second psychiatrist appointment	350.00	130.85	219.15
Follow-up appointment with a psychiatrist - standard	250.00	85.00	165.00
Follow-up appointment with a psychiatrist - extended	350.00	130.85	219.15
Follow-up appointment with a psychiatrist - long	600.00	255.90	344.10
Script outside of appointment	60.00	-	60.00
Letter for travel or confirmation of medication	44.00	-	44.00
Letter to third party	Varies	-	Varies

New ADHD referrals that are accepted must pay a deposit of $250 to confirm their 3 sessions. A second payment of $600 must be preauthorized before the first consult with our psychiatrist, and a third payment of $350 must be preauthorized before the second consult with our psychiatrist. Medicare rebates apply to all consultations with our psychiatrist. If you intend to claim any refunds through your private health insurer, please check if they provide cover for outpatient psychiatry appointments. We will send you reminders for your appointments and information how to pay online a week before each appointment.

All follow up appointments must be preauthorized up to 6 days before each appointment and not later than 1 day before your appointment.

If you wish to cancel or move your appointment, we request you provide as much notice as possible and not less than one weeks’ notice for initial appointments. Missing an initial appointment or providing less than one weeks’ notice to cancel or move will incur a $250 fee. Missing a follow-up appointment or cancelling or moving with less than 24 hours’ notice will incur a $100 fee. If you need to change an appointment, please let us know as soon as possible. We have Telehealth facilities available for follow up appointments if you are Covid positive, have cold and flu symptoms but are still feeling well enough to attend.

Terms of Service(Required)

I have read the Financial Disclosure and agree with all terms of service.

I agree to the Terms of Service

Form 005 Patient Consent to Collect & Disclose Information
Effective 1 August 2024

The Privacy Act 1988 requires medical practitioners to obtain consent from their patients to collect, use or disclose patients' personal information.

Collection

My practice staff and I will collect information that is necessary for me to properly advise and treat you. Such necessary information may include:

▪ Full medical history

▪ Family medical history

▪ Ethnicity

▪ Contact details

▪ Medicare and private health fund details

▪ Billing and account details

▪ Clinical evaluations

The information will normally be collected directly from you. There may be occasions when we need to obtain information from other sources with your prior consent. In emergency situations, we may have to collect information from relatives or other sources without your prior consent.

Use and Disclosure

With your consent, we will use and disclose your information for purposes such as:

▪ Account keeping and billing

▪ To reply to your referring doctor

▪ To keep your other health providers informed

▪ Referral to another doctor or health care provider

▪ Management of my practice

▪ Quality assurance, practice accreditation and complaint handling and ongoing research

▪ To meet our obligations of notification to medical defence organisation or insurer

▪ To prevent or lessen a serious threat to an individual’s life, health or safety

▪ Where legally required to do so, such as producing records to court, mandatory reporting of child abuse or notification of certain communicable diseases

Access

You are entitled to have access to your own health records at any time convenient to both yourself and the practice. Depending on the nature of the access requested a charge might be payable where the practice incurs costs in providing access. There are some circumstances in which access may be denied, but in such an event, you will be advised of the reason. If you find any information we hold on you that is inaccurate or incomplete, please advise us so that we can record your corrections. We are not able to erase the original record.

Consent(Required)

I confirm that I have received and read the “Financial Disclosure” form and the “ADHD Assessment and Treatment Process”, which details the consultation fees that I will be charged and information about the assessment process.
I provide my consent for Dr Larissa Harding and her practice staff to collect, use and disclose my personal information as outlined.

I understand that I am entitled to have access to my medical records except for some circumstances.

I understand that I may withdraw, in writing, my consent to use and disclose my personal information at a later date, except when legal obligations must be met.

I confirm my consent

Deposit

Price:

Total

Credit Card

Name

This field is for validation purposes and should be left unchanged.

	Yes	No
Have you ever been diagnosed with any major mental condition such as Schizophrenia or Bipolar Affective Disorder?
Have you been diagnosed with personality Disorder?
Have you ever been diagnosed with Anorexia Nervosa and currently experiencing problems maintaining weight?
Have you ever attempted suicide?
Have you been admitted to a psychiatric hospital?
Have you ever received treatment for substance use
Do you currently use any illicit substances including cannabis?
In the last 12 months, have you been taking medication for ADHD?
Do you drink alcohol excessively?
Do you have history of violence or legal problems?
Is anyone from your family attending Mind and Brain Clinic?

Mind & Brain Clinic

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M&B Form 027 Script Request

Mind & Brain Clinic

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M&B Form 028 Document Upload

M&B Form 027 Script Request

M&B Form 004 - Preauthorization

M&B Form 003 Registration

ADHD Assessment and Treatment Process
Effective 1 August 2024

ADHD Assessment Process

Financial Disclosure
Effective 3 September 2024

Form 005 Patient Consent to Collect & Disclose Information
Effective 1 August 2024

M&B Form 002 Referral Upload

M&B Form 012 ADHD Assessment and Treatment Process

Form 012 ADHD Assessment and Treatment Process
Effective 1 August 2024

ADHD Assessment Process

M&B Form 006 Financial Disclosure

Financial Disclosure
Effective 3 September 2024

M&B Form 030 Appointment Request

Form 027

M&B Form 027 Script Request

M&B Form 029 Travel Letter Request

M&B Form 028 Document Upload

M&B Form 027 Script Request

M&B Form 004 - Preauthorization

M&B Form 003 Registration

ADHD Assessment and Treatment ProcessEffective 1 August 2024

ADHD Assessment Process

Financial Disclosure Effective 3 September 2024

Form 005 Patient Consent to Collect & Disclose InformationEffective 1 August 2024

M&B Form 002 Referral Upload

M&B Form 012 ADHD Assessment and Treatment Process

Form 012 ADHD Assessment and Treatment ProcessEffective 1 August 2024

ADHD Assessment Process

M&B Form 006 Financial Disclosure

Financial Disclosure Effective 3 September 2024

M&B Form 030 Appointment Request

ADHD Assessment and Treatment Process
Effective 1 August 2024

Financial Disclosure
Effective 3 September 2024

Form 005 Patient Consent to Collect & Disclose Information
Effective 1 August 2024

Form 012 ADHD Assessment and Treatment Process
Effective 1 August 2024

Financial Disclosure
Effective 3 September 2024