Client Registration Register to become a client.Date* InformationName* First Last Nicknames or AliasesDate of Birth* AgeAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Mobile Phone*Home PhoneEmail* Calls and emails will always be handled discreetly, but please note any restrictions Medicare Number in format - all number(s) in front of your name on card.Your Reference # on card (number in front of your name)Expirey DateReferralHow did you find out about my service?Emergency ContactIf some kind of emergency arises and we cannot reach you directly, or we need to reach someone close to you, whom should we call?Contact NameContact PhoneContact RelationshipContact AddressConsentPlease rest assured that all client details are held in the strictest confidence, and are only available to you and to your doctor. Psychological Service. As part of providing a psychological service to you, Dr Peter Eide will need to collect and record personal information from you that is relevant to your current situation. This information will be a necessary part of the psychological assessment and treatment that is conducted. You do not have to give all your personal information, but if you don’t, this may mean the psychological service may not be able to be provided to you. Purpose of collecting and holding information. The information is gathered as part of the assessment, diagnosis and treatment and is seen only by the Dr Peter Eide. The information is retained in order to document what happens during sessions, and enables the psychologist to provide a relevant and informed psychological service. Access to Client Information. At any stage you as a client are entitled to access to the information about you kept on file, unless the relevant legislation provides otherwise. Dr Peter Eide may discuss with you appropriate forms of access. Confidentiality. All personal information gathered by Dr Peter Eide during the provision of the psychological service will remain confidential and secure except where: Failure to disclose the information would place you or another person at serious and imminent risk Your prior approval has been obtained to (a) provide a written report to another professional or agency. eg. a GP or a lawyer (b) discuss the material with another person, eg. a parent or employer It is subpoenaed by a court If disclosure is otherwise required or authorised by law. Fees. All payments are due at the end of each session and payments are accepted by Eftpos, Visa, Mastercard or cash. If you need to cancel your appointment please contact me at least 24 hours before your appointment, otherwise you will be charged a cancellation fee. Charter for Clients of Psychologists. The attached Charter explains your rights as a client of a psychologist.Consent to treatment terms.I have read and understood the above Consent Form. I agree to these conditions for the psychological service provided by Dr Peter Eide. I accept PhoneThis field is for validation purposes and should be left unchanged.