Service Agreement for Psychological Services

Please complete this form before your first appointment. We recommend setting aside 1 hour for this.

Welcome to aMAZEin’ Minds Psychology! We are looking forward to working with you. Please read the following Services Agreement, and if you are happy to proceed, please sign at the bottom of the Services Agreement. If you have any questions, please ask us before signing via telephone or email at (03) 7046 4528 or info@amazeinminds.com.au

aMAZEin' Minds Psychology Pty Ltd (ACN 660 276 175)


This form is for:


For client's younger than 18 years old, 

This form has been completed by:

Services Agreement

This Services Agreement ("Agreement") is between aMAZEin' Minds Psychology Pty Ltd (referred to as "we," "us," or "our") and you, the Client, or the person signing this Agreement on behalf of the Client (referred to as "you"). Together, both are referred to as the "Parties," and individually as a "Party."

This Agreement should be read alongside our Privacy Policy, which you can find at www.amazeinminds.com.au/privacy-policy, or request a copy from our office.

1. Acceptance and Term

You accept this Agreement by signing and returning it to us, either on paper or electronically.

This Agreement starts on the date you accept it and will end on the earlier of:

  • (a) when the Agreement is terminated as described in the termination clauses, or

  • (b) 12 months after your last appointment.

2. Services

In exchange for the agreed Price, we will provide the Services outlined in this Agreement.

Our Services are delivered by qualified psychologists and include psychological assessments, interventions, counselling, professional supervision, and consultation.

We commit to providing these Services in line with our professional and ethical obligations, including the Australian Psychological Society’s Code of Ethics and Ethical Guidelines.

2.1 AMP Psychologists

When you book an Appointment for Services, you can choose which AMP Psychologist you’d like to see. If you're unsure, let us know, and we'll assign an AMP Psychologist based on their expertise and availability.

If your chosen AMP Psychologist is temporarily unavailable (e.g., due to illness, leave, or other reasons), we will work with you to arrange how, when, and with whom the Services will be provided.

2.2 Emergency Support

Please note that we do not offer emergency or crisis support, nor do we provide Services outside of scheduled Appointments. If you are in crisis, please call 000 (emergency services) or 13 11 14 (Lifeline). Additional crisis support numbers and resources are available at https://www.amazeinminds.com.au/resources/

2.3 Translation

Our Services are provided by English-speaking AMP Psychologists. If you need translation or interpretation support, we recommend that you arrange this yourself, as our Services may be less effective if there is a language barrier. If you need help finding a translator, please let us know, and we can suggest some resources.

2.4 Telehealth

If we agree to provide Services via telehealth, we will send you a link to our conferencing platform for your Appointment. You are responsible for having a device with a speaker, microphone, camera, a reliable internet connection, and a quiet, private space before the Appointment.

Please note that telehealth Services may have some limitations (see www.amazeinminds.com.au/faqs for more details). We may decide that certain Appointments must be held in person, and we can decline a telehealth Booking if we believe in-person attendance is necessary.

2.5 Recordings

Appointments, including those via telehealth, must not be recorded unless both Parties agree in advance.

3. Additional Services

You can request Additional Services from us, such as drafting letters or reports. The Price for these services will be based on the time it takes to prepare them, charged at an hourly rate. We will give you a cost estimate for your approval before starting any Additional Services. Please note that these services are not covered by Medicare.

4. Appointments

4.1 Making an Appointment

During the Term, you can schedule an Appointment by contacting us via phone, email, or through our online booking system. 

Once your Appointment is confirmed, we will send you an email with the date and time. 

Unless we agree otherwise, all Appointments will be held at our office at 11B/475 Blackburn Road, Mount Waverley, VIC 3149.

4.2 Cancellation

Please read our cancellation policy carefully, to understand what cancellation fees may be charged to you if you cancel within the times set out below (Cancellation Fees).


Note that the notice period is in relation to Business Hours (as indicated on our website https://www.amazeinminds.com.au)

You agree that the Cancellation Fee is a fair estimate of our losses when we can’t fill your slot on short notice.

We may send appointment reminders by email or SMS as a courtesy. However, not receiving a reminder is not a valid reason to avoid cancellation fees.

If we need to cancel your Appointment, no Cancellation Fee will be charged, and we will do our best to reschedule your Appointment as soon as possible.

5. Payment

You agree to pay the Price for each Appointment in exchange for the Services we provide. The Price depends on the length of the Appointment, the type of Service, and the qualifications of the AMP Psychologist. Our Price list is available on our website: www.amazeinminds.com.au/services-fees

For in-clinic Appointments, payment is due at the end of each Appointment, unless we agree otherwise. We will not release any drafted documents (e.g., reports) until they are paid for in full. Payment can be made via EFTPOS, credit card, direct debit, or direct bank deposit.

For telehealth Appointments, you must pay the Price at least 24 hours before your scheduled Appointment, using the payment method in our invoice.

If you do not pay on the day of the Appointment, we reserve the right to:

  • (a) charge 10% interest on the Price;

  • (b) refer the collection to a third party, such as a debt collector; or

  • (c) refuse any future Appointments until the Price is paid in full.

5.1 Current Fees

Assessment Sessions

  • Registered Psychologists: $280 per 50-minute session

  • Provisionally Registered Psychologists: $180 per 50-minute session

  • Comprehensive Report (mandatory for all assessments): $1400 per report

    Note: Assessments typically require multiple sessions and include a comprehensive report with findings and recommendations. The number of sessions depends on the type and complexity of the assessment.

Counselling/Therapy

  • Registered Psychologists:

    • Initial 50-minute Consultation: $280

    • Subsequent 50-minute Sessions: $250

  • Provisionally Registered Psychologists:

    • Initial 50-minute Consultation: $180

    • Subsequent 50-minute Sessions: $150

Other Services

  • Shorter Reports: Pricing provided upon request based on requirements.

  • Specialised Services: Fees for extended sessions or additional consultations will be discussed and agreed upon individually.

5.2 Medicare Rebate

To be eligible for Medicare rebates on eligible Services, you need a valid referral from your doctor. Please discuss this with your doctor before your Appointment. 

While we can help you with the steps to claim a rebate, we are not responsible for your eligibility or if you provide incorrect Medicare details or ineligible referral. 

We aim to process the Medicare claim on the day of your Appointment, and the rebate will be sent to the bank account you have registered with Medicare.

5.3 Private Health Rebate

If you have private health insurance, you may be eligible for rebates on eligible Services. It's your responsibility to check your eligibility and submit receipts to your insurance provider to get reimbursed. We do not process private health insurance claims for you.

5.4 Changes to Our Hourly Rates

We may adjust our hourly rates each year on 1 July. We will notify you of the updated Price before your next Appointment. If you do not agree with the new Price, you can cancel your Appointment without any penalty.

6. Confidentiality

We are committed to keeping all information you share with us private and confidential, as required by our professional and legal obligations. However, there are some situations where we may need to share your information:

  • (a) If your parent or guardian has a legal right to access your information;

  • (b) If you give us permission to share your information with someone else, like another health professional, lawyer, family member, teacher, or funding body;

  • (c) If sharing the information is necessary for the main reason it was collected, such as providing a treatment progress report to your referring doctor;

  • (d) If we are legally required to share the information, such as in response to a subpoena, government requirements, reporting child neglect or abuse, or for audits;

  • (e) If we believe there is an immediate risk of harm to you or someone else, and sharing the information could prevent that harm;

(f) If we need to discuss your case during professional supervision, we will do so without revealing your identity or that of any related individuals.

7. Consent Orders & Court Orders

You agree to give us a copy of any consent or court orders involving the Client before we start providing Services. This is especially important if the orders affect the Services or who can access the Client's confidential information. We will keep this information confidential, as outlined in this Agreement.

7.1 Separated Parents/Legal Guardians

Before we begin providing Services, you are responsible for identifying who has legal authority over the dependent Client.

If there are no consent orders in place, both parents/guardians share equal responsibility for decisions about the child, including healthcare. However, if we find out that one legal guardian does not consent to our Services, we may choose to stop or not start providing Services to the Client, based on professional and ethical considerations.

8. Privacy

Collecting personal and sensitive information is necessary for us to provide the Services.

We comply with the Australian Privacy Principles under the Privacy Act 1988 (Cth) and any other relevant laws or privacy guidelines.

Please read our Privacy Collection Notice below, which explains how we use and share the personal information we collect during the Services. You can also review our full Privacy Policy at www.amazeinminds.com.au/privacy-policy

8.1 Privacy Collection Notice

This Privacy Collection Notice describes how we collect and handle the personal and sensitive information you provide to us e.g., when completing this online intake form.

We collect personal and sensitive information from you, and from third parties (such as your referring doctor) so that we can provide our Services to you and for related purposes set out in our Privacy Policy, available at: www.amazeinminds.com.au/privacy-policy, or you can ask us for a copy of our Privacy Policy at our office. We may disclose this personal information to third parties, including service providers who assist us to provide our Services, and as otherwise set out in our Privacy Policy (linked above).

While we store personal information in Australia, where we disclose your personal information to the third parties listed above, these third parties may store, transfer or access personal information outside of Australia. If you do not provide your personal information to us, we may not be able to provide the Services to you.

Please see our Privacy Policy (linked above) for more information about how we collect, store, use and disclose your personal information, including details about overseas disclosure, access, correction, how you can make a privacy-related complaint and our complaint-handling process.

By providing your personal information to us, you agree to the collection, use, storage and disclosure of that information as described in this privacy collection notice.

If you have questions about our privacy practices, please contact us by email at: info@amazeinminds.com.au

8.2 Use of AI Assistance in Treatment Notes

We may utilise AI-assisted software to support the drafting and organisation of treatment notes. This technology is used as a tool to enhance efficiency and accuracy in record-keeping; however, all notes are reviewed and finalised by a qualified professional to ensure accuracy, relevance, and confidentiality.

Where AI-assisted software is used for these purposes, we utilise Heidi Notes, a secure clinical documentation platform that includes AI-assisted features to support the drafting and organisation of treatment notes. Heidi Notes uses recorded audio from sessions to generate summaries and assist in documentation. These AI tools help streamline record-keeping while maintaining high standards of accuracy and compliance.

Your privacy remains our priority, and any information processed through AI assistance is handled in accordance with our privacy policy and applicable legal and ethical standards. If you have any concerns or wish to opt out of AI-assisted documentation, please discuss this with your psychologist.

9. Retaining Health Records

By law, if the Client is 18 years or older when we create or update their health record, we will keep those records for at least seven years from the last contact with the Client, unless other legal or organisational rules apply.

For records created when the Client is under 18, we will keep them until the Client turns 25, unless other legal or organisational rules require otherwise.

10. Intellectual Property

We own all Intellectual Property Rights in Our Materials, including anything we create when providing Additional Services to you, like reports or resources.

You own (or hold a licence for) any materials you provide to us during the Services.

We give you a non-exclusive, revocable, worldwide right to use Our Materials, but you cannot transfer this right to others unless we agree. This right is only for your use and enjoyment of the Services.

You give us a non-exclusive, irrevocable, worldwide right to use any materials you provide to us, but only for fulfilling our obligations or exercising our rights under this Agreement. This right cannot be transferred to others, except to our related companies.

This clause remains in effect even after this Agreement ends.

11. Charter for Clients

The Australian Psychological Society (APS) has a Charter for Clients that explains the standards you can expect from our psychologists. You can view it on our website or on the APS’s website.

12. Australian Consumer Law

Consumer Law Rights:Under Australian Consumer Law and similar protections, you may have rights, warranties, guarantees, and remedies related to the Services we provide that cannot be excluded, restricted, or changed. This Agreement does not override those Consumer Law Rights.

Subject to your Consumer Law Rights, we exclude all warranties, and all material, work and services (including the Services) are provided to you without warranties of any kind, either express or implied, whether in statute, at Law or on any other basis, except where expressly set out in this Agreement or otherwise in writing. All materials, work, and Services are provided "as is," without any other guarantees, unless specifically stated in this Agreement or in writing.

13. Limitations on Liability

To the extent allowed by law and subject to your Consumer Law Rights: 

  • (a) Neither party will be responsible for indirect or secondary losses (called "Consequential Loss"), like lost profits or missed opportunities. 

  • (b) If a problem happens and both parties are partly responsible, each party’s responsibility (or "Liability") will be reduced based on how much they contributed to the issue, including not taking steps to minimise the loss.

  • (c) If we fail to meet your Consumer Law Rights, our Liability is limited (at our discretion) to supplying the Services again or paying the cost of having the Services supplied again.

  • (d) Our total responsibility for any Liability arising from or in connection with this Agreement is limited to the Price you paid us for the relevant Services related to which the Liability relates.

This clause will apply and survive the termination or expiry of this Agreement.

14. Term and Termination

You can end this Agreement at any time by giving us written notice. However, if you cancel an Appointment within 48 Business Hours, you are still required to pay the Cancellation Fee.

We can terminate this Agreement by giving you written notice in the following situations:

  • (a) You have not paid the Price for Services already provided;

  • (b) We believe there is an issue that prevents us from delivering competent Services;

  • (c) We are unable to continue providing the Services; or

  • (d) It is reasonably clear that the Client is not benefitting from the Services.


Upon expiry or termination of this Agreement:

  • (a) we will immediately cease providing the Services; 

  • (b) you are to pay for all Services provided prior to termination, including Services which have been provided and have not yet been invoiced to you, and all other amounts due and payable under this Agreement; 

  • (c) upon your request, we must destroy or return your confidential information, except for any confidential information required to be maintained by law; and 

  • (d) where required, we will use reasonable endeavours to ensure that there is continuity in psychological services for the Client. 

Termination of this Agreement will not affect any rights or liabilities that a Party has accrued under it. 

This clause will survive the termination or expiry of this Agreement.

15. General

15.1 COVID-19 Policy

We prioritise everyone’s safety when visiting our office. As a publicly accessible healthcare facility, we follow all Victorian Government rules to reduce COVID-19 risks.

For in-person Appointments, you must follow our current COVID-19 Policies, which are summarised on our website at www.amazeinminds.com.au. If you or your guardian do not follow these guidelines, you will not be allowed on the premises, and your Appointment may be cancelled.

You can request a full copy of our COVID-19 Safe Plan by contacting our admin team via phone or email.

15.2 Complaints

You have the right to share your concerns or make a complaint, and we are committed to addressing them fairly and efficiently. Complaints and feedback help us improve our Services. You can find our Complaints Policy on our website.

If there is a dispute, controversy, or claim related to this Agreement (including any question regarding its existence, validity, or termination), both Parties must first try to resolve it in good faith before starting court proceedings. This does not stop either Party from seeking urgent legal action, like an injunction, from a court if necessary.

16. Additional Provisions

Amendment: Subject to the clause regarding our Price variation, this Agreement may only be amended by written instrument executed by the Parties. 

Assignment: a Party must not assign or deal with the whole or any part of its rights or obligations under this Agreement without the prior written consent of the other Party (such consent is not to be unreasonably withheld). 

Assignment of Debt: You agree that we may assign or transfer any debt owed by you to us, arising under or in connection with this Agreement, to a debt collector, debt collection agency, or other third party. 

Electronic Execution: This Agreement may be executed using an Electronic Signature. The Parties acknowledge and agree that if a Party executes this Agreement using an Electronic Signature, then the Party is taken to have entered into this Agreement in electronic form and the Electronic Signature is deemed to be an original execution of the Agreement by the Party. “Electronic Signature” means an electronic method of signing that identifies the person and indicates their intention to sign this Agreement which may include software programs such as Docusign. 

Force Majeure: Neither Party will be liable for any delay or failure to perform their respective obligations under this Agreement if such delay or failure is caused or contributed to by a Force Majeure Event, provided that the Party seeking to rely on the benefit of this clause: 

(a) as soon as reasonably practical, notifies the other party in writing details of the Force Majeure Event, and the extent to which it is unable to perform its obligations; and

(b) uses reasonable endeavours to minimise the duration and adverse consequences of the Force Majeure Event.

Governing law: This Agreement is governed by the laws of Victoria. Each Party irrevocably and unconditionally submits to the exclusive jurisdiction of the courts operating in Victoria and any courts entitled to hear appeals from those courts and waives any right to object to proceedings being brought in those courts. 

Notices: Any notice given under this Agreement must be in writing addressed to the addresses set out in this Agreement, or the relevant address last notified by the recipient to the Parties in accordance with this clause. Any notice may be sent by standard post or email, and will be deemed to have been served on the expiry of 48 hours in the case of post, or at the time of transmission in the case of transmission by email. 

Relationship of Parties: This Agreement is not intended to create a partnership, joint venture, employment or agency relationship between the Parties.

17. Definitions

In this Agreement, unless the context otherwise requires or unless otherwise set out in the Agreement, capitalised terms have the meanings given to them in the Schedule, and: 

Additional Services means any additional services you request us to provide, such as preparation of reports and other documentation. 

ACL or Australian Consumer Law means the Australian consumer laws set out in Schedule 2 of the Competition and Consumer Act 2010 (Cth), as amended, from time to time. 

AMP Psychologist means a psychologist who is employed to perform Services at aMAZEin’ Minds Psychology. 

Agreement means these terms and conditions and any agreed Appointment issued under it and any documents attached to, or referred to in, each of them. 

Business Day means a day on which banks are open for general banking business in Victoria, excluding Saturdays, Sundays and public holidays. 

Consequential Loss means, whether under statute, contract, equity, tort (including negligence), indemnity or otherwise:

(a) any loss or damage that cannot be considered to arise according to the usual course of things from the relevant breach, act or omission, whether or not such loss or damage may reasonably be supposed to have been in the contemplation of the Parties at the time they entered into this Agreement as the probable results of the relevant breach, act or omission; and/or

(b) without limiting subclause (a), any real or anticipated loss of profit, loss of benefit, loss of revenue, loss of business, loss of goodwill, loss of opportunity, loss of savings, loss of reputation, loss of use and/or loss or corruption of data.

However, the Parties agree that your obligation to pay us the Price under this Agreement will not constitute “Consequential Loss”.

Force Majeure Event means any event or circumstance which is beyond a Party’s reasonable control including but not limited to, acts of God including fire, hurricane, typhoon, earthquake, landslide, tsunami, mudslide or other catastrophic natural disaster, civil riot, civil rebellion, revolution, terrorism, insurrection, militarily usurped power, act of sabotage, act of a public enemy, war (whether declared or not) or other like hostilities, ionising radiation, contamination by radioactivity, nuclear, chemical or biological contamination, any widespread illness, quarantine or government sanctioned ordinance or shutdown, pandemic (including COVID-19 and any variations or mutations to this disease or illness) or epidemic.

Intellectual Property Rights or Intellectual Property means any and all existing and future rights throughout the world conferred by statute, common law, equity or any corresponding law in relation to any copyright, designs, patents or trade marks, domain names, know-how, inventions, processes, trade secrets or confidential information, circuit layouts, software, computer programs, databases or source codes, including any application, or right to apply, for registration of, and any improvements, enhancements or modifications of, the foregoing, whether or not registered or registrable. 

Laws means all applicable laws, regulations, codes, guidelines, policies, protocols, consents, approvals, permits and licences, and any requirements or directions given by any government or similar authority with the power to bind or impose obligations on the relevant Party in connection with this Agreement or the supply of the Services.

Liability means any expense, cost, liability, loss, damage, claim, notice, entitlement, investigation, demand, proceeding or judgment (whether under statute, contract, equity, tort (including negligence), indemnity or otherwise), howsoever arising, whether direct or indirect and/or whether present, unascertained, future or contingent and whether involving a third party or a Party to this Agreement or otherwise.

Our Materials means all Intellectual Property which is owned by or licensed to us and any improvements, modifications or enhancements of such Intellectual Property, including any reports or other documents we prepare and provide to you in the course of providing the Services.

Price means the fees for the Services and/or Additional Services, as set out in our price list (available on our website), or as otherwise quoted to you, as updated in accordance with this Agreement.

Schedule means the schedule to this Agreement.

Services means the psychology services you request us to provide under this Agreement.

Your Materials means all Intellectual Property owned or licensed by you, including any existing medical reports, which you provide to us in order for us to provide the Services.



EXECUTED AS AN AGREEMENT

Signed by Client

EXECUTED AS AN AGREEMENT

Signed by Parent/Guardian

EXECUTED on behalf of Client by a parent or guardian, who is authorised to sign this Agreement on behalf of the Client:

Clear

Court Orders

Court Orders MUST be provided to us before the first appointment by:


Failure to provide these documents can result in refusal of services.

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Personal & Contact Details

List relationships, ages, and names. If applicable, list how often the Client spends time across different households.

Parent/Legal Guardian Information

Parent/Legal Guardian #1

Parent/Legal Guardian #2

Emergency Contacts

List Emergency Contact(s)* that you consent to your Psychologist contacting in circumstances where your psychologist is (a) concerned about the welfare of the referred Client and/or (b) is unable to contact you.

*LIST PEOPLE WHO ARE NOT LEGAL GUARDIANS


Referral Information

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What are the main types of challenges, difficulties, and/or barriers has the client been experiencing?
e.g., What would you like to improve? What sorts of supports would you like to have implemented? What guidance or advice would you like? What would you like to do more of? less of? If you were living life the way you want, what would you be doing differently?

Previous Assessments and Interventions

e.g., psychological, speech pathology, OT
e.g., psychological, speech pathology, OT

Please Upload any Documents relating to previous Assessments or Interventions below.

Alternatively, email them to info@amazeinminds.com.au

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Authority to Release or Collect Information

Your Psychologist may need to gather information from, and/or share information with, other professionals involved in your care. The information that is collected and/or shared by your Psychologist will be for reasons directly related to the Services being provided to you.


Please list the people who can be contacted for information collection and/or sharing purposes related to the Services.

Examples include, but are not limited to:

  • wellbeing staff (e.g., school- or work-based wellbeing teams, counsellors)

  • educators (e.g., teachers, tutors)

  • allied health practitioners (e.g., psychologists, speech pathologists, OTs)

  • non-referring doctors

  • employers


Background Information

Yours answers to the following questions can help your Psychologist prepare their upcoming sessions with you in ways that can match your needs and goals.

Personality

What are they like with other people? What are they like when they are by themselves?

Medical History

Family History

e.g., changes in family life, divorce, moving homes, trauma, assault, death/grief, new family member, job loss

Developmental History


Educational History

Preschool/Kinder, Primary, Secondary, Tertiary
e.g., Prep to 6
e.g., something teachers do, strategies the client developed on their own

Learning Supports and Interventions

e.g., private tutoring, in-class support
e.g., reading, phonological processing, maths
e.g., learning support officer, classroom teacher, private tutor
e.g., weekly, 3x per week, daily
e.g., 2020 Term 1, start of Grade 3
e.g., March 2019

Please provide recent school reports, individual learning plans (ILP/PLP), and any other important school-related documents by:

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Current Presentation

Social-Emotional Wellbeing and Support


Task Approach and Focus


Self-Regulation

e.g., blurting out answers, interrupting others while they're speaking, difficulty waiting in a queue

Conclusion