Background Information

If your GP has previously referred you for psychological support during the current calendar year, please advise us as this may affect your Medicare rebate.

Please provide the following information to ensure that our records are correct and to provide information to the psychologist who will be treating you. This page asks for general information about you and the page overleaf asks about the specific problem/s that you would like to address.

Contact phone numbers. Please indicate whether it is permissible to leave a message on each of the numbers by circling either yes or no

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CONSENT FORM

Psychological Service

As part of providing a psychological service to you, your psychologist will need to collect and record personal information from you that is relevant to your current situation. This information is a necessary part of psychological assessment and treatment. You do not have to give all your personal information, but if you don't, the psychological service may not be able to be provided to you or may not be optimally beneficial to you.

Purpose of collecting and holding information

The information is gathered as part of assessment, diagnosis and treatment, and is seen only by your psychologist. The information is retained in order to document what happens during sessions, and to facilitate relevant and informed psychological service.

Access to Client Information

At any stage you 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.

Confidentiality

All personal information gathered by the psychologist during the provision of the psychological service will remain confidential and secure except in the following instances:

1. It is subpoenaed by a court
2. Failure to disclose the information would place you/another person at serious & imminent risk
3. Your prior approval has been obtained to
   1. Provide a written report to another professional or agency. e.g. a GP or a lawyer
   2. Discuss the material with another person, e.g. a parent or employer or if disclosure is otherwise required or authorised by law.

Fees

The cost of a 50 minute consultation varies and will be discussed with you when you book your first appointment. If you are attending sessions privately, or under Medicare, the fee is payable at the end of the session by either cash, EFTPOS or credit card.

Cancellation Policy

If, for some reason you need to cancel or postpone the appointment, please give at least 24 hours notice, otherwise your deposit will be forfeited. Forfeited deposits will need to be paid before further sessions can be booked.

Charter for Clients of Psychologists

The Charter (see display in waiting area) explains your rights as a client of a psychologist. I,

have read and understood the above Consent Form. I agree to these conditions for the psychological service provided by Psychology Perspective.