Child Consent Form

Psychological Service
As part of providing a psychological service to you, your Psychologist will need to collect from and record personal information about 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 are under no obligation to do so, however if you don’t, this may mean that the psychological service may not be able to be provided to you.
N.B. If your visit is part of a legal or compensation claim, or Court Order e.g. Worksafe, TAC, Victim’s Compensation, Probation and Parole, or other, you must inform your Psychologist as soon as you are aware, due to complex reporting and planning requirements.

Purpose of collecting and holding information
The information is gathered as part of assessment, diagnosis and treatment purposes, and is accessed only by the Psychologist. The information is collected and retained in order to document what happens during sessions, and enables the Psychologist to provide a relevant and informed psychological service. If you are under a Mental Health Plan a report will be sent to your referring GP.

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. Your Psychologist may discuss with you, appropriate forms of access.

Confidentiality
All personal information gathered by the Psychologist during the provision of the psychological service will remain confidential and secure except where:
1. It is subpoenaed by a court, or
2. Failure to disclose the information would place you or another person at serious and
imminent risk; or
3. Your prior approval has been obtained to
a) provide a written report to another professional or agency. eg. GP or a lawyer; or
b) discuss the material with another person, eg. a parent or employer; or
4. If disclosure is otherwise required or authorised by law.

Fees for Professional Service: payable at the time of service
Cost have been discussed with you on first contact.

A Medicare rebate is payable to those on a Mental Health Care Plan (MHCP).

Payment Methods – three methods:
1. If you have a MHCP from your GP, and have given your bank details to Medicare, the rebate ($87.15) can be automatically credited to your account upon payment of the fee for professional service.
2. Claim your rebate by presenting the receipt of payment to Medicare,
3. If you do not have a MHCP, you may claim a rebate by presenting the receipt of payment to your private health fund. Contact your fund for advice on amount of rebate.

Cancellation Policy
If you need to cancel or postpone the appointment, contact me as soon as possible, giving at least 48 hours notice, so that this appointment can be made available to another on the waitlist. Failure to do so may result in being charged the cost for the session.

Child Consent Form