Consent Form Child

Child Consent Form

As part of providing a psychological service to you, your psychologist will need to collect and record personal information that is relevant to your current situation. Collection of personal information is a necessary part of psychological assessment and therapy.

Information is gathered as part of the assessment, diagnosis and treatment of a client’s condition, and is only seen by the psychologist. The information is retained in order to document what happens during sessions, and enables the psychologist to provide a relevant and informed psychological service. The psychology services provided by your clinic are bound by the legal requirements of the National Privacy Principles from the Privacy Amendment (Private Sector) Act 2000. All communications between you and your psychologist become part of your clinical records, which are stored in your client file. Client filesare held in asecure filling cabinet and electronically that is accessible only by your treating psychologist.

With the exception of certain specific exceptions as described below, you have the absolute right to confidentiality of your information.You are assured that all personal information gathered by the psychologist during the provision of the psychological service will remain confidential and secure. However, it is important to know that there are exceptions in which all psychologists are mandated (by law) to break confidentiality. This can occur when:

  1. The information you have given to your psychologist is subpoenaed (officially requested) in a court of law
  2. Failure to disclose the information would place you or another personat serious risk of harm
  3. Your prior approval has been obtained to:
    1. Provide a written report to another professional or agency e.g. GP or lawyer
    2. Discuss the material with another person e.g. A parentor employer

There may be times where, as part of the assessment and therapy process, it may be helpful for your psychologist to liaise with other people or agencies that are relevant to your therapy goals (e.g. Your GP, specialist, parent, WorkCover, etc). Please note that if you intend to claim rebates from Medicare or another organisation (such as WorkCover or TAC) then your psychologist must provide summary reports to external agencies regarding your treatment progress. Under the Medicare scheme these reports will normally be sent to your GP or psychiatrist.

If therapy is begun, sessions are typically scheduled once per week for 50minutes at a time you and your therapist agree on, although some sessions may be longer or more frequent. Couples, family or group therapy sessions may be routinely scheduled for 90 minutes or longer. Missed sessions and late arrivals are problematic for both clients and therapists.Therefore, we ask clients to make a commitment to attend regularly. If you find regular attendance is a problem for you, we ask that you consider whether this is the most appropriate time or type of clinic for you. At times, you may do better to terminate therapy and start at a later date when you can make a regular commitment.

Fees are payable at the time of consultation.

As you can understand, it is nearly impossible for a psychologist to book a new client at very short notice. A late cancelled appointment is a loss to three people:

  1. The client who is delaying their therapy progress
  2. Another client who has been sitting on the waiting list to see the psychologist urgently
  3. The psychologist who has spent the morning preparing for the session

Our clinic policy on missed and late appointments is as follows:

  1. A minimum of 24 hours’ notice is required for cancellation and you will not incur a cancellation fee
  2. Cancelling an appointment within 24 hours when under no extenuating circumstances such as illness or emergency incurs a full fee of $190 which will be charged and required to be paid when you call to cancel your appointment
  3. If you have cancelled or missed a session it is your responsibility to contact the clinic to reschedule
  4. If you miss two or more session in a row, without calling to cancel or reschedule, your therapist will try to contact you by phone. If we are unable to contact you, we will send you a letter and we will assume that you are well and no longer require our services.
  5. If you miss two or more session in a row, without calling to cancel or reschedule, your therapist will try to contact you by phone. If we are unable to contact you, we will send you a letter and we will assume that you are well and no longer require our services.
  6. Therapists are required to inform the director of Anxiety House of recurrent late cancellations or missed appointments.

Following your assessment you and your clinician will develop a treatment plan. At our clinic we pride ourselves on meeting and exceeding your treatment needs. In order to do so, we will regularly seek feedback both verbally and electronically. This may mean that at times after your session you may be required to stay an extra 10 minutes to answer several carefully selected questions to assess that we are meeting your needs. These tests also measure outcomes so we can ensure that treatment is moving in the right direction and if not, problem solve why it is not. This information is stored securely in paper and electronic files and only your psychologist has access to this information.

By ticking the boxes below this indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. If you have any questions or are unclear about any policy, please feel free to discuss these with your therapist prior to signing this document.

 
 
 
 
 
 
 
 
 
Upload Signature

Please provide the following information for our records. Leave blank any question you would rather not answer. Information you provide here is held to the same standards of confidentiality as our therapy.

   
Surname, Firstname, MI
Number and Street, Suburb, State, Postcode
   
           
    May we leave a message?
    May we leave a message?
*Please be aware that email may not be confidential
    May we email you?
Surname, Firstname, MI
   
(eg. GP – Carina Medical Centre)
   
   
   
   
         
(e.g. Chronic pain, headaches, hypertension, diabetes, etc.)
   
         
   
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Family Mental Health

 
 
 
 
 
 
 
 
 
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