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Dear Client,
Please note that all information provided in this Questionnaire will be kept strictly confidential in line with our policies outlined in“Provision of Psychological Services”(see attached).
Please note that you are required to complete section A (Personal Details), whereasresponses tosections B toIarenot essential. However, should you decide to complete these sections, your responses will provide an insight into some of your current attitudes and motivations, and are thuslikely to better inform the psychological services offered to you.
If you have any queries about the questions or your responses to the questions, please discuss your concerns with me at your next appointment.
PLEASE REMEMBER TO BRING THIS FORM TO YOUR NEXT VISIT
A)Personal Details:
Date:Medicare No:
Ms./Mrs./Mr. Full Name:
Date of Birth:Address:
Occupation:
Daytime Ph: Evening Ph: Mb Phone:
Email: Marital Status:
Have you ever been diagnosed with any of the following: Epilepsy: Depression: Psychosis: Schizophrenia: Bi Polar Disorder: Multiple Personality Disorder; Borderline Personality Disorder?
If Yes, please identify what applies andwhen it has been diagnosed (year and month)?
Any Other Known Significant Mental Health Issues (if yes, please identify):
List any medications you are currently taking:
B)Briefly answer the following questions:
- If you had to pick only one word to describe your life, what would it be?
- If you had to pick only one word to describe your problems, what would it be?
- If you had to pick only one word to describe the good times in your life, what would it be?
C)Please complete the following sentences:
One of the things I feel proud of is
One of the things I feel guilty of is
I am happiest when
If I were not afraid to be myself, I would
I get so angry when
I am most saddened by
All my life
Ever since I was a child
One of the ways I could help myself is
It is hard for me to admit
I am a person who
A mother should
A father should
A true friend should
Please note down your most significant memory, experience or event from each of the following ages. Include all ages – even past your age (where you imagine yourself at that age). If you cannot recall a significant event, just skip the line.
0-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
D)Please give short answers to the following questions:
What motivates you?
What makes you happy?
Which behaviors do you believe are getting in the way of your happiness?
What would you like to start doing more of?
What would you like to stop doing?
E)Please give short answers to the following questions:
What would you like to be doing 5 years from now?
What do you see or imagine yourself doing in 5 years from now?
What do you see or imagine yourself doing in 6 months from now?
What would have to change or be different for that to happen?
F)Complete the following statements:
I truly believe that
I also truly believe that
I truly value that
I also truly value that
G)Please answer the following question in only two or three sentences
For what particular issue/problem are you seeking help?
In your opinion, what could be causing these kinds of problems/issues?
When we make that change you have come here to see me for, how would this positively affect your life (list 5 – 7 changes)?
H) Please answer the following questions ONLYif you consider the use of HYPNOTHERAPY:
Do you have any fears or phobias, if so, please describe:
List your most favorite relaxing activities (i.e. walking, swimming, etc) and favorite places (i.e. beach, forest, mountains, etc)
Have you been hypnotized before? If yes, for what
Statement for the Provision of
Psychological Services
This document provides information relating to psychological services supplied by Jorg Thonnissen(Psychologist), the limits of confidentiality, as well as describing Jorg Thonnissen’s policy for the management of clients’ information. The psychological services provided by Jorg Thonnissen (referred to hereafter as ‘the psychologist’) are bound by the legal requirements of the:
Psychologists Act 2005 (WA)
National Privacy Principles from the Privacy Act (1988)
Health Privacy Principles from the Health Records Act 2001
Australian Psychological Society (APS) Code of Ethics
Management of Clients’ Personal Information
As part of providing psychological services to you that may include (but is not limited to) counselling, motivational interviewing, problem-solving skills training, cognitive-behavioural therapy, psychological assessment, group therapy, relaxation strategies, skills-training, hypnotherapy; the psychologist will need to collect and record personal information from you that is relevant to your current situation.
Purpose of collecting and holding information
This information is a necessary part of the psychological assessment, diagnosis and/ or treatment that is conducted and may include information, data and results from questionnaires, interviews, referrals from third parties or other sources, and/ or the consultation session itself; and may incorporate written information as well as audio and visual images from digital recordings.
The information is seen only by the psychologist, and is retained in order to document what happens during sessions, and to enable the psychologist to provide a relevant and informed psychological service to you. You do not have to give all your personal information, but if you do not, this may mean that psychological services may not be able to be provided to you.
Client Information
Client files are held in a secure filing cabinet, which is accessible only to authorised employees of the psychologist. The information on each file includes personal information such as name, address, contact phone numbers, and any other information which is relevant to the psychological service/s being provided.
Confidentiality
All personal information gathered by the psychologist during the provision of the psychological service will remain confidential and secure except where:
- It is subpoenaed by a court, or
- Failure to disclose the information would place you or another person at serious and imminent risk; or
- Your prior approval has been obtained to:
a)provide a written report to another professional or agency. eg. To provide feedback to the GP who prepared a GP Mental Health Care Plan to refer you to the psychologist under the Allied Health and Dental Services Initiative; or
b)discuss the material with another person, eg. a parent or employer.
There are other situations when disclosure of your personal information is permissible without your consent; or in situations when disclosure of your personal information is otherwise required or authorised by law to prevent, investigate or prosecute a crime or offence, e.g. suspected child abuse. In these circumstances, only the minimum necessary information will be conveyed.
Requests for 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. The psychologist may discuss with you appropriate forms of access. All requests by clients for access to information held about them should be lodged with Jorg Thonnissen, Principal Psychologist. These requests will be responded to within 14 days and an appointment will be made if necessary for clarification purposes.
Concerns
If you have a concern about the management of your personal information, please inform Jorg Thonnissen, Principal Psychologist. Upon request, you can obtain a copy of the National Privacy Principles/ Health Privacy Principles, which describe your rights and how your information should be handled. Ultimately, if you wish to lodge a formal complaint about the use of, or access to, your personal information, you may do so with the:
Office of the Federal Privacy Commissioner on 1300 363 992, or GPO Box 5218, Sydney, NSW 1042
Office of the Health Services Commissioner on 1800 136 066, or 30th Floor, 570 Bourke St, Melbourne, VIC 3000
Fees
The type and cost of our Initial and Standard consultation sessions are outlined below. The cost for one consultation (usually consisting of between 40-90 minutes in consultation with the client and 10 minutes for the recording of information from the consultation) is listed below. These fees are usually payable at the end of the consultation, and can be paid either by cash, cheque or direct debit (please ask for account details if this is your preferred payment option).
Please note that our prices with Medicare rebate and withoutMedicare rebate (Full Fee) for focused psychological services provided at our Consulting Room for Individuals are as follows:
TYPE FULL FEE MEDICARE REBATE GAP
Initial Consultation (120-180min) $250.00$80.20 (item80110)$169.80
Long Consultation(90-100min)$190.00$80.20 (item80110)$109.80
Standard Consultation (60-70min)$130.00$80.20 (item80110)$49.80
In addition to prices indicated above, services provided outside of the Consulting Room (i.e. home visitations) attract travel charges (see below):
TYPETERM OF PAYMENTFEE
Travel to and from locationpay on the day$80(within Perth area)
Please note: for services provided at other locations, higher Medicare rebates apply (i.e. $98.40 per session based on MBS item 80115 for 50+ minutes consulting time). In some cases, discounted charges (Full Fees) may apply to clients who can provide evidence that they are experiencing financial hardship. The provision and applicable amount of such discounts are entirely at the discretion of the psychologist.
Cancellation Policy
If, for some reason you need to cancel or postpone the appointment, please give at least 12 hours notice, otherwise you may be charged the cost for the session.
Please Note: If, after reading these pages, you are at all unsure of what is written, please discuss it with your psychologist.
Mental Health Support
Lifeline’s ph: 13 11 14 service is staffed by trained volunteer telephone counsellors who are ready to take calls 24-hour a day, any day of the week from anywhere in Australia. These volunteers operate from Lifeline Centres in every State and Territory around Australia. Lifeline answers around 450,000 calls per year from people needing emotional support.
Anyone can call Lifeline. The 13 11 14 service offers a counselling service that respects everyone’s right to be heard, understood and cared for. We also provide information about other support services that are available in communities around Australia.
Somewhere in Australia there is a new call to Lifeline every minute. People call about many things and needs of callers may vary across genders and age groups and between rural and metropolitan areas.
Lifeline telephone counsellors are ready to talk and listen no matter how big or how small the problem might seem. They are trained to offer emotional support in times of crisis or when callers may be feeling down.
Go to for detailed information
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Department of Health ph:1300 135 030 service
There is a comprehensive range of public mental health services. Mental health care is provided for children, adolescents, adults and older people.
Services are provided through community mental health units, hospitals and community health centres.
There is also a wide network of non-government organisations not listed in this directory that provide many important mental health services with assistance from the State Government.
Information on these services is available from HealthInfo 1300 135 030.
General practitioners are able to help people with mental illness and make referrals to specialist mental health services when needed.
Go to for detailed information
BeyondBlue ph: 1300 22 4636 service
beyondblue is a national, independent, not-for-profit organisation working to address issues associated with depression, anxiety and related substance misuse disorders in Australia.
beyondblue is a bipartisan initiative of the Australian, state and territory governments with a key goal of raising community awareness about depression and reducing stigma associated with the illness.
beyondblue works in partnership with health services, schools, workplaces, universities, media and community organisations, as well as people living with depression, to bring together their expertise around depression.
Go to for detailed information
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WAAMH ph: (08) 9420 7277
Vision
WAAMH works towards a future in which the health and well being of people affected by mental illness is promoted and supported by a range of community based mental health services and in which there is community acceptance of people with mental illness.
Mission
WAAMH is the peak mental health representative body in Western Australia for non-government not-for-profit agencies that operate for the benefit of people affected by mental illness. WAAMH supports and encourages the development of the non-government not-for-profit mental health sector for the benefit of people affected by mental illness.
Go to for detailed information
For psychological emergency support contact Lifeline’s 24-hour free Counseling Service on 13 11 14