Thank you for your enquiry regarding Irabina’s Paediatric Clinic.

Please complete and submit the intake form, consent form and background information questionnaires in this form prior to your appointment.

Please include copies of any reports that have been previously completed (e.g. psychometric assessment, speech and language assessment, school report).

Should you have any further questions, please do not hesitate to contact the Irabina Paediatric Clinic on (03) 9720 1118.

Please read through the information and agreements in this section regarding privacy, consent, cancellation and fees.

We will ask for your signature in agreement at the end of this section.

Fee Payment, Cancellation, and Non-attendance

One of our friendly staff members will email you an invoice within a day of your appointment. A follow up call will then be made then next day to discuss available payment options - either over the phone, via eftpos or online.

New Patient Consulation (First visit):

• Type of visit: Standard consultation
• Duration: 60 mins
• Full Fee: $450
• Medicare rebate: $236.95
• Out-of-pocket expense: $213.05

Review Consultation (Follow-up visit)

• Type of visit: Standard consultation
• Duration: 30 mins
• Full Fee: $250
• Medicare rebate: $118.65
• Out-of-pocket expense: $131.35

This fee must be paid before any further services are provided by Irabina Autism Services.

In extenuating circumstances, the decision to waive the cancellation fee is made by the relevant Doctor. It cannot be made by the administrative staff.

Consent to Maintain Records/Information

I hereby consent to Irabina keeping records (either paper or electronic format) about the services provided.

I understand that:

• These records are owned by Irabina
• Information within these records will be shared with other staff within Irabina on a ‘need to know’ basis, if and only when the staff require the information to carry out their duties.
• My consent will be obtained if any records need to be released to another agency or if another agency is contacted to provide information.
• I can ask to see records and receive a copy.
• Records are archived by IRABINA according to policy and will eventually be destroyed.

Irabina is required to comply with the Australian Privacy Principles (APP) in the Privacy Act 1988 (Cth) and the Health Privacy Principles in the Health Records Act 2001 (Vic).

This means that Irabina must conform to:

• The kinds of information that Irabina may collect about you and how that information is held.
• How Irabina collects and holds personal information.
• The purpose for which Irabina collects, holds, uses and discloses personal information.
• How you can access the personal information that Irabina holds about you and seek to correct such information.
• The way in which you can complain about a breach of your privacy and how Irabina will handle that complaint.

Informed Consent/Confidentiality

Your privacy is important to us and would like for you to feel comfortable speaking openly about your concerns with our professionals. We hope the following information will clarify our privacy policies.

In most cases, all information you provide to our professionals here are completely confidential. This means that, without your written permission (the two sections above), no information you have with us will be available to anyone outside of Irabina. Nonetheless, there are some exceptions to this and we would like for you to be aware of the following:

• If you or your child/young person poses a threat of harm to yourself or to another person, we will take whatever steps required by law, or permitted by law, to help prevent the potential harm from happening.
• If you report information indicating that a child/young person, disabled, or elderly person is suffering abuse or neglect we will take whatever steps required by law, or permitted by law, to protect the person in question.
• If a court order issued by a judge requires us to release information contained in your records, or when a therapist is required to testify, we will comply with the court order.

I have read and discussed the above information with a professional from Irabina. I have been given the opportunity to discuss any concerns about these matters and understand the nature and limits of confidentiality. I agree to the above information.

The following information will provide Irabina preliminary information about the child/young person. Please answer these questions with as much detail as possible.