Informed Consent Form The following describes the policy of this practice for the management of client’s information (privacy policy), as well as the policies regarding confidentiality, fees, payments, and cancellations. The psychology services provided by the psychologists at this practice are bound by the legal requirements of the Australian Privacy Principles (2014) (APP) and the Victorian Health Privacy Principles (HPP). In signing this form, you are consenting to the provision of psychological services by your psychologist to yourself/your child and indicating your understanding of the policies outlined below. Purpose of Collecting and Retaining Information As part of providing a psychological service to you/your child, your psychologist will need to collect and record personal information from you/your child that is relevant to you/your child’s current situation. Information is gathered as a necessary part of the assessment and treatment of your/your child’s needs/condition and may be seen only by your psychologist (Dr Cody Potter). The information is retained in order to document what happens during sessions and enables your psychologist to provide a relevant and informed psychological service. The information is stored electronically in your/your child’s client file. Confidentiality All personal information gathered by your psychologist during the provision of the psychological service will remain confidential and secure except where: 1. The information you have given to your psychologist is subpoenaed by a court of law 2. Failure to disclose the information would place you/your child or another person at serious risk of harm 3. Your prior approval has been obtained to a) provide a written report to another professional or agency, for example, your GP b) discuss the material with another person, for example, parents or school teacher Please note these confidentiality guidelines also apply to child clients who are old enough to provide such approval. Please note that in the event of COVID-19 exposure at the practice, we will need to provide the required contact details for relevant clients to public health officials. Exchange of Client Information 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/your child’s therapy goals (e.g., your GP, specialist, parent, school or childcare staff, etc.). Your psychologist will seek your approval to discuss your personal information with these people whenever possible. Please note that if you intend to claim rebates from Medicare then your psychologist must provide summary reports to the referring doctor regarding your assessment and treatment progress. These reports will normally be sent to your/your child’s GP, pediatrician, or psychiatrist. Access to client information At any stage you as a client are entitled access to the information about you kept on file unless the relevant legislation indicates otherwise. The psychologist may discuss the contents with you and/or they may provide a copy of the information. An appointment will be made if necessary, for clarification purposes. Fees & Cancellation Policy The cost of a 55-minute consultation is $210 and the cost of a $110 minute consultation is $380. Additional fees may be charged for reports. Fees are due in full on the day of the appointment. If for some reason you need to cancel or postpone the appointment, please provide at least 48 hours’ notice. If less than 24 hours’ notice is given you will be charged the 50% of the appointment fee. Providing the appropriate referrals to be eligible for Medicare rebates is your responsibility and not the responsibility of your psychologist. Remembering appointment times is your responsibility. Please do not rely completely on the SMS reminder system. Crisis or Emergency Services Your psychologist is not able to provide crisis or high dependency services. Should you require support for a crisis or after hours emergency, please contact the Child, Adolescent or Adult Mental Health Services in your area (see www.health.vic.gov.au to locate the appropriate service to assist you in your area). The following telephone counselling services may also be of support. Lifeline: 13 11 14 Kids Help Line: 1800 551 800 Parentline: 13 22 89 Confirmation of Informed Consent I, (print name) …………………….………………………………………………………………... have read and understood the above Consent Form. I agree to these conditions for the psychological service provided by Dr Cody Potter to myself/my child. (print child’s name if relevant)……………………………….......................................... Signature ……………………………………………………………………. Date …………………………………...………………………………………. Thank-you for completing this form. Should you have any questions about anything on this form, please don’t hesitate to ask during your appointment before signing.
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