Consent Form

Psychological Services

As part of providing a psychological service  to you, Australian Clinical Psychologists  needs to collect and record personal information from you that is relevant to your situation, such as your name, contact information, medical history and other relevant information as part of providing psychological services to you.

This collection of personal information will be a necessary part of the psychological assessment and treatment that is conducted.

Purpose of collecting and holding information

Your personal information is gathered as part of your assessment and treatment is kept securely and, in the interests of your privacy, used only by your psychologist and the authorised personnel of the practice (as necessary). Your personal information is retained in order to document what happens during sessions, and enables the psychologist to provide a relevant and informed psychological service to you. A more detailed description is provided in the practice’s “Privacy policy for management of personal information”, which can be obtained on request. The Privacy Policy contains information about how to access and seek correction of your personal information, and how to lodge a complaint about our management of your personal information.

Consequence of not providing personal information

If you do not wish for your personal information to be collected in a way anticipated by this letter or the Privacy Policy, Australian Clinical Psychologists may not be in a position to provide the psychological service to you. You may request to be anonymous or to use a pseudonym, unless it is impracticable to deal with you or if Australian Clinical Psychologists is required or authorised by law to deal with identified individuals. In most cases it will not be possible for you to be anonymous or to use a pseudonym, however if the agreed to then you must pay consultation fees at the time of the appointment.

Access to client information

At any stage you are entitled to access your personal information kept on file, subject to exceptions in the relevant legislation. The psychologist may discuss with you different possible forms of access.

Disclosure of personal information

All personal information gathered by the psychologist during the provision of the psychological service will remain confidential except when:
1)  it is subpoenaed by a court; or
2)  failure to disclose the information would in the reasonable belief of the psychologist place you or another person at serious risk to life, health or safety; or
3)  to provide a verbal or written report to another professional or agency. e.g., a lawyer; or
4)  to discuss the material with another relevant person, eg. a parent, employer or health provider; or
5)  to disclose the information in another way requested by you; or
6)  when one would reasonably expect your personal information to be disclosed to another professional or agency such as your referring doctor, and disclosure of your personal information to that third party is for a purpose which is related to the purpose for which your personal information was collected; or
7)  when making associated referrals for yourself or others such as family members as agreed with the psychologist; or
8)  disclosure is otherwise required or authorised by law.

Fees

The cost of a consultation (usually around 50 minutes) is $220, which is payable at the end of the session by electronic card (credit, savings or cheque) unless prior agreement has been provided by Australian Clinical Psychologists that treatment costs will be covered by a third party payer.

Cancellation Policy

If, for some reason you need to cancel or postpone your appointment, please give the psychologist at least 48 hours notice, otherwise you will be charged a cancellation fee of $100.

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