Setup > Intake templates

Intake serves a couple of purposes. You have to manage first impressions, risk, logistics and it can also serve as an opportunity to make the assessment and formulation data gathering a little smoother. The following is a set up what we use as our starting point in any PowerDiary setup for the intake process. For reference what we are enabling is the following flow chart.

Click image to expand or open the pdf

Steps

Intake Notes template

 Phone based intake give us an opportunity to manage first impressions and personalise the next steps to be relevant to the client calling. That could be in terms of asking triage questions of a eating disordered or depressed person, it could be quickly identifying a mismatch in needs and services or sending appropriate history forms that allow you to decide if this presentation is a good match given your current caseload. We try to limit an intake calls to around 5-10 minutes otherwise we find that some clients don't tend to tolerate much more but we can use it as an opportunity to branch into alternates intake notes templates if the various switching questions at the end are endorsed. Our standard questions that you can import  and edit are: 

General Intake

Intake officer*

Intake information provided by (full name, phone and email. If not client - then relationship with client)*

IF CHILD / ADOL / YOUNG Person: What are the names of all biological parents, carers or guardians*

Main concern / GP or similar diagnosis*

Previous therapy*

What would you / they most like assistance with at this time? What would you / they most like to get out of coming here?*

What times of day / days of week would be impossible to attend appointments? Are telehealth appointments possible?

Other comments / Observations*

Branching triage

Safety Questions

I have a couple of standard safety questions that may or may not apply but I need to ask everyone who presents. Is that OK?

IF CHILD / ADOL / YOUNG PERSON - "Are you currently in a relationship with the other parent?" If no.... then endorse... or if presented by step parent etc then endorse

Self / Other harm - "Have you / they had any thoughts about harming yourself or others? Have you / they ever acted on those, and harmed yourself or someone else?"

Eating Disorder - "Are you / they experiencing any issues with food, weight or body image?"

Psychosis - "Have you / they had any experiences like seeing things that other people don't see, hearing voices, disturbing thoughts or images?"

History Email 

The email template that links to the history form needs to be created. This is what we suggest:

Template details	Wording
Name: Intake History (Adult) Desc: This is sent by reception after a phone intake to gather more information as part of the overall intake process From: YourReception@yourdomain Subject: Intake Form {OnlineForm:XX}: Should be replaced by the form ID in the next step	Hi {RecipientPreferredName}, Thank you for your call today. Please complete the self referral form below so that {AppointmentPractitionerShortName} can have a better understanding of what you have been up against and what your goals of treatment might include.  {OnlineForm:XX}   Let me know if you have any further questions of if we can help in anyway.  Kind Regards, <Reception Signature>

History Form

JotForm 

JotForm costs $29USD pm but it does come with a lot more features than PowerDiary such as the ability to ask conditional questions that show / hide fields or pages and it also allows upload of things like MHCP paperwork or to take photos of referrals or Medicare cards. The downside is that it isn't integrated so you lose the capability to have clients update their name or phone number if you accidentally typo it. If you are a customer of our Virtual Admin service then we can host these forms for you saving you the cost of the annual licencing. See this article for more info and to clone the intake form if you choose to do it yourself.

PowerDiary forms

Clicking on the embedded link in the above email will take the client to the following PowerDiary portal form which you are welcome to import and edit:

Your Details

First Name

Last Name

Date of Birth

Mobile Phone

Email

Street Address

Suburb

State

Postcode

I identify my sex as _______________ (e.g., male, female....)

I identify my gender as _______________ (e.g., man, woman, genderqueer, non-binary ....)

Medical/Referral Details

Who recommended the practice to you? If it was a doctor, please provide their name, provider number and whether they gave you a copy of a Mental Health Care Plan

Are you happy for us to let your GP and/ or Psychiatrist know that you have contacted us?

If no, that's okay. Out of interest, please let us know your concerns about us contacting them.

Do you have a friend or family member who is coming to the practice at the moment or has attended previously? If so, what is their name and your relationship with them?

Current Medications

Rebates

We don't require referrals for most presentations but we will do whatever we can to help clients who have referrals receive rebates that can apply if the correct paperwork is in place. Please note we are not a bulk billing practice so even if you do have a care plan there is likely to be a gap for sessions. If you do have a care plan please email it separately to us as we aren't able to upload it directly.

Rebate type

I am not expecting rebates - I'll be privately paying

I have a GP plan for 10 sessions

Current Situation

What is the nature of your concerns at this time?

When did these current concerns start and when did they intensify? Are there any events which may have contributed to this situation?

Other stressors? For example: “We moved house in January… “ etc

What would you most like to get out of coming?

Additional information

Are there any other professionals involved at the moment? E.g., dietitians, psychiatrist

Have you had any previous therapy? What was the main focus of therapy at that time (e.g., friendships, depression, anxiety)? How long did they attend treatment for? How regularly did you attend? Which approach (if known) was used by the therapist e.g., CBT, ACT, DBT, Family Sys, solution focussed, psychodynamic? What was their experience of therapy? How did they relate or find the therapist as a person? Did they feel comfortable with them? Can you think of ways that the relationship could have been improved? How effective was the treatment?

Please let us know anything else that you feel is important for us to be able to help you at this time.

Appointments and availability

What times of the day are impossible for you to attend on an ongoing basis?

Waiting lists and Refer on

There may be clients where you aren't ethically able to take them on for some reason or if you could but are currently booked out then you will need to communicate this to them. We would encourage you to build up a collection of email templates that each relate to a presentation type that explain the waiting list process and refer them to the resources that are on your website or elsewhere that might help them with managing their distress at not being able to commence immediately, help them gain some basic understanding of what is going on and perhaps start monitoring their symptoms in a structured way. This is something that reception would not typically be involved with. 

Confirmation

Having decided that you are willing and able to take on this client then the next step is to gather the informed consents and send the logistical details to the client ahead of their first appointment. 

This email template that links to the consent form needs to be created. This is what we suggest:

Template details

Wording

Name: IA Confirmation (Adult) Desc: Sent to all new clients ahead of their first appointment From: YourReception@yourdomain Subject: Intake Form {OnlineForm:XX}: Should be replaced by the form ID in the next step ###portal### should Have a hyperlink added using the value from Setup > Client Portal > Access and Settings - Copy URL

Dear {RecipientPreferredName}, I am pleased to confirm your appointment with {ClientPreferredDiaryRealName} on {AppointmentDate:ddd d MMM} at {AppointmentStartTime}{AppointmentLocationNotes}.  We need to gather an informed consents and other details prior to your first appointment. Please complete our online consent form prior to your appointment {OnlineForm:XX}.  {ClientPreferredDiaryRealName} has also requested that you complete these standardised measures prior to your initial appointment. Please follow the link below.  ###insert NovoPsych link here.  The fee for the first session is $XXX. The fees for ongoing sessions with {ClientPreferredDiaryShortName} are usually $XXX. NB: Fees are subject to change over time but please talk to us about any financial barriers to treatment.  If there are any changes to this appointment or subsequent bookings you can log onto our  ###portal###. Please note that because you are already in our system you simply need to use the "Reset Password" function and your {RecipientEmailAddress} email address. If you prefer you can contact reception or myself via email reception@yourdomain or by calling {BusinessPhone} between 8:00am - 6:00pm. Please provide more than one business day (24 hours) notice on cancellations as fees are charged for late cancellations. If you are planning connecting remotely and would like to check that Zoom is working before your appointment then you can use my Zoom link below and I would be very happy to help you with any technical difficulties before your appointment so as not to impact on your time with {ClientPreferredDiaryShortName}. Please don't hesitate to contact me if there is anything further that I can help with. Kind Regards, <Reception Signature>

Consent forms

 The following is our default consent and rebate form you are free to import and edit. 

Consent

Fees and cancellation

Fees are based on a 50 min hour with 10 min note taking time and are charged proportionally for contact (in person, phone or email); report preparation and court waiting time. Fees are payable at the time of consultation. Cash, cheque and Credit Card payments are accepted, but EFTPOS (Cheque and Savings accounts) are not. Please note that unless there are exceptional circumstances the full fee is charged for sessions that are cancelled less than one business day (Monday to Friday 9:00am-5:00pm – 24hrs) prior to the scheduled appointment time.

Privacy and confidentiality

Psychological Service:
As part of providing a psychological service we 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 may view and/or have a copy of the
material recorded in your file upon request, subject to the exemptions in National Policy Principle 6.

Confidentiality
Any issues raised during a session or phone consultation will remain strictly confidential. Without your written consent, subpoena or similar legal requirement to disclose, this information will not be discussed with any third party including partners, family members, GPs or other health professionals. Please note that all our staff are bound by a strict confidentiality code.

Privacy and Data Security
Like most health service providers we collect information which is covered by the Privacy Act 1988. This information includes name and contact details as well as diagnostic and treatment information to enable us to provide psychological treatment. From time to time the practice conducts and
publishes research however all data is depersonalised before doing so. This information is stored in PowerDiary's cloud database. We also use a service called FIT-Outcomes based in Ireland for session by session effectiveness tracking. The only personal data supplied to this service is your internal reference code, your first name and year of birth. In addition we use the Zoom meetings product that has been upgraded to the HIPAA compliant version which means that all data is encrypted at rest and across the web and in addition we enforce configurations to prevent accidental breaches of privacy such as disabling recording. Please let us know if you have any privacy concerns. Please let us know if you have any privacy concerns.

Permission to Consult / Release Information
Any issues that arise as part of assessment and treatment will remain strictly confidential. Without your written consent, this information will not be discussed with any third parties. We do however encourage a collaborative approach with referrers, GP’s and schools or other involved parties. Please take a moment to consider which if any of the following parties you are happy for us to contact to gain additional information, which of those you are happy for us to release information to and to what extent if any you would like that information to be restricted.

Please list any professionals with whom you consent to us collaborating with. Please note Medicare rebates are not available unless consent is given to collaborate with the referrer.

Consent

Due to current legislation, your written consent to the above information is required. I would therefore ask that you sign the consent below prior to your first session.
If you have any further questions before you attend your first session, please do not hesitate to contact us.
Yours sincerely
Reception - Clinical Psychology

I have read and understood the attached Information form. I agree to these conditions for the psychological services provided including the confidentiality and cancellation policies.

I hereby give consent anonymous questionnaire results to contribute to the ongoing research and evaluation of programs

I am happy to receive occasional communications including resources for common challenges and announcements relating to the services at <Business Name>.

I would like appointment reminders sent: *

via SMS 3 days out

via Email 3 days out

Via SMS the day before

No reminders

Signature*

Payments and Rebates

Credit Card Authority

We use an online credit card payment system called Stripe which is integrated with PowerDiary rather than swipe terminals. This involves us entering your card number into PowerDiary and having it automatically authorised through the Internet using Stripe in a similar fashion to online shopping. Cash and cheques are also available, but if you do sign this form you are agreeing to us debiting the cost of consultations, late cancellations etc at the time payment falls due and posting a receipt if you are not present.
This agreement will remain in place until you complete treatment or ask us to remove your card details from our system. If you have any questions or concerns about this, please don’t hesitate to call or speak to reception on {BusinessPhone}. We will ask you to provide your credit card number in person at the time of the first consult, over the phone or via our line portal following your first consult. This consent is visible to all reception staff so we only ask for the last 4 digits of your card as a reference.

Name on Card

Last 4 digits of your Credit Card Number

Medicare Rebates

If you have a GP Mental Health Care Plan that has been completed by your GP prior to your appointment and your session qualifies with the various requirements for rebates then either you can submit claims yourself, or if you share your Medicare information with us we can do it on your behalf so that at the time of your appointment or shortly after, we will
take the full fee and then put the claim through to Medicare and typically 24 hours later they will deposit the rebate into your bank account directly.

Medicare Rebates

I will not be claiming through Medicare

I would like claims processed on my behalf

Attendee details

Medicare requires the clients details on all claims

Full name of person attending appointments

Medicare Card Number

Reference Number (Number next to attendees name on card)

Expiry Date

Payee's details

If someone other than the attendee such as a parent will be paying for appointments then we also require their details in order to process Medicare claims. Please skip to the consent if you are paying for your own sessions.

Full name of person paying for sessions (If different from above)

Payer's Date of Birth

Phone Number

Street Address

Medicare Card Number (if different from above)

Reference Number

Expiry Date

I hereby agree to payments being taken and rebates being submitted as described above*

 

NDIS Service Agreement form

With thanks to Chelsea Brigginshaw via the Power Diary Facebook group the following is our default NDIS Service Agreement form you are free to import and edit. 

Parties

This service agreement is between Clinical Psychology Centre and

 

First Name*

Last Name*

Date of Birth*

Participant's Representative's name*

The Participant's Representative can be contacted on

The Clinical Psychology Centre can be contacted on

ph: 1300 120 648
em: [e-mail]

Service Agreement

This document is an Agreement that relates to the provision of supports that the National Disability Insurance Scheme (NDIS) has agreed to pay for.

 

1. Parties

This Service Agreement is between the participant or participant's representative in the NDIS and Clinical Psychology Centre the Provider.

2. The NDIS and this service agreement

This Service Agreement is made for the purpose of providing supports under the participant’s National Disability Insurance Scheme (NDIS) plan.

The parties agree that this service agreement is made in the context of the NDIS, which is a scheme that aims to:

• Support the independence and social and economic participation of people with disability, and
• Enable people with a disability to exercise choice and control in the pursuit of their goals and the planning and delivery of their supports.

3. Schedule of supports

The provider agrees to provide the participant Psychological Therapy Services including sessions with the below duration and frequency.

The supports and their prices are set out in the attached schedule of supports.
All prices GST inclusive (if applicable) and include the cost of providing the supports. Additional expenses (i.e. things that are not included as part of a participant’s NDIS supports) are the responsibility of Participant’s representative and are not included in the cost of the supports.

Duration

50 min (plus 10 min note taking)

75 min (plus 15 min note taking)

100 min (plus 20 min note taking)

Frequency

Weekly

Fortnightly

Every 4 weeks

4. Responsibilities of Provider

The Provider agrees to:

• Review the provision of supports at least 6 months with the participant
• Once agreed, provide supports that meet the participant’s needs at the participant’s preferred times
• Communicate openly and honestly in a timely manner
• Treat the Participant with courtesy and respect
• Consult the participant on decisions about how supports are provided
• Give the participant information about managing any complaints or disagreements and details of the provider’s cancellation policy.
• Listen to the participant’s feedback and resolve problems quickly
• Give the participant a minimum of 24 hours notice if the provider has to change a scheduled appointment to provide supports
• Give the participant at least 2 weeks notice if the provider needs to end the service agreement
• Protect the participant’s privacy and confidential information
• Provide supports in a manner consistent with all relevant laws, including the National Disability Insurance Scheme Act 2013 and rules, and the Australian Consumer Law; keep accurate records on the supports provided to the participant, and
• Issue regular invoices and statements of the supports delivered to the participant.

5. Responsibilities of Participant’s representative

The Participant’s representative agrees to:

• Inform the provider about how they wish the supports to be delivered to meet the Participant’s needs
• Treat the provider with courtesy and respect
• Talk to the provider if the participant has any concerns about the supports being provided
• Give the provider a minimum of 24 hours’ notice if the Participant cannot make a scheduled appointment; and if the notice is not provided by then, the provider’s cancellation policy will apply.
• Give the provider the required notice if the participant needs to end the service agreement and
• Let the provider know immediately if the participant’s NDIS plan is suspended or replaced by a new NDIS plan or the participant stops being a participant in the NDIS.

6. Changes to this Service Agreement

Service Agreement has to be reviewed at least once in 12 months.

If changes to the supports or their delivery are required, the parties agree to discuss and review this service agreement. The parties agree that any changes to this service agreement will be in writing, signed, and dated by the parties.

7. Ending this Service Agreement

Should either party wish to end this service agreement they must give at least 2 weeks notice.

If either party seriously breaches this service agreement the requirement of notice will be waived.

8. Feedback, complaints and disputes

If the participant wishes to give the provider feedback, the participant can talk to Adam Davis on 1300 120 648
If the participant is not satisfied or does not want to talk to this person, the participant can contact the National Disability Insurance Agency by calling 1800 800 110, visiting one of their offices in person, or visiting ndis.gov.au for further information.

9. Goods and services tax (GST)

For the purposes of GST legislation, the parties confirm that:

• A supply of supports under this service agreement is a supply of one or more of the reasonable and necessary supports specified in the statement included, under subsection 33(2) of the National Disability Insurance Scheme Act 2013 (NDIS Act), in the participant’s NDIS plan currently in effect under section 37 of the NDIS Act;
• The participant’s NDIS plan is expected to remain in effect during the period the supports are provided; and
• The participant’s representative will immediately notify the provider if the participant’s NDIS Plan is replaced by a new plan or the participant stops being a participant in the NDIS.
• In the ‘Change of Circumstance’ clause, providers may need to consider that the participant will not intend to renew their NDIS Service Agreement when their 2nd, 3rd etc. plan has commenced.

10. Payments

The provider will seek payment for the provision of supports after the service has been provided. Payment is to be received within 7 days of the service being provided. Except for in the case of a report, where payment must be completed before the release of the report.

The Participant's representative has chosen to use the following funding for NDIS support provided under this service agreement*

Self Managed

Plan-Managed

NDIA-Managed

Participant's NDIS Number*

11. Travel

The Clinical Psychology Centre may claim travel costs against the participant's NDIS Plan in order to provide the service. The below cost has been agreed to and will be charged for each appointment.

Travel charged per session*

Schedule of supports

Psychological Therapy Services

$ 180: Therapy Session (50 mins plus 10 min note taking)
$ 90: Brief Letter (30 mins)
$ 360: NDIS Report

Signature

Participant's Representative agrees to the terms and conditions of this Service Agreement*

Adam Davis on behalf of The Clinical Psychology Centre agrees to the terms and conditions of this Service Agreement

Last Updated: 22 October 2021