Consent Form
Counselling Service
As part of providing counselling service to you, your practitioner at Crookes Counselling & Consulting Service will need 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 counselling services to you.
The collection of personal information will be a necessary part of the psychological assessment and treatment that is conducted.
Purpose of Collecting & Holding Information
Your personal information is gathered as part of your assessment and treatment; it is kept securely and, in the interests of your privacy, used only by your treating practitioner and the authorised personnel of the practice (as necessary). Your personal information is retained in order to document what happens during sessions and enables your treating practitioner to provide a relevant and informed counselling service to you.
A more detailed description is provided in the practice’s “Privacy policy for management of personal information”, available here or asking for a copy at reception. 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.
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 practitioner may discuss with you different possible forms of access.
www.health.vic.gov.au/healthrecords/
Disclosure of personal information
All personal information gathered by the practitioner during the provision of the counselling service will remain confidential and secure except when:
- It is subpoenaed by a court; or disclosure is otherwise required or authorised by law; or
- Failure to disclose the information would in the reasonable belief of your practitioner at Crookes Counselling & Consulting Service place you or another person at serious risk to life, health or safety; or
- Your prior approval has been obtained to:
(a) provide a written report to another professional agency, eg, GP or a lawyer; or
(b) discuss the material with another person, eg, a parent or employer or health provider; or third party funder; or
(c) disclose the information in another way; or
(d) disclose to another professional or agency (e.g. your GP) and disclosure of your personal information to that third party is for a purpose which is directly related to the primary purpose for which your personal information was collected.
Your personal information is not disclosed to overseas recipients, unless you consent or such disclosure is otherwise required by law. Your personal information will not be used, sold, rented or disclosed for any other purpose.
In the event that unauthorised access, disclosure or loss of a client’s personal information occurs, Crookes Counselling & Consulting Services will activate its data breach action procedures and use all reasonable endeavours to minimise any risk of consequential serious harm.
Telehealth
sessions:
I
understand that my psychologist is taking the necessary precautions to ensure
confidentiality
including:
• Ensuring the privacy of the telehealth session is upheld in the same way
an in-person
session
would be, by choosing a private location or using headphones
• Not allowing any voice or video recording
of the session
Fee policy
Fees
Pre-payment will be taken over the phone the day before your appointment, our reception staff will contact you to arrange this payment.
Refer to our fee schedule for current Fees & Rebates. If fees are not paid on the day of consultation, a late payment fee of $10.00 will be charged.
Weekend and After-Hours Rates
Please note higher fees apply
Method of Payment
You can pay by EFTPOS, credit card or cash.
Cancellation Policy
If for some reason you need to cancel or postpone the appointment, please give us at least 24 hours
notice, otherwise full fees will be incurred.
48 hours’ notice is required to cancel or postpone a Sunday appointment; otherwise full fees will be
incurred.
Failure to attend 2 consecutive appointments without notice will result in the closure of your file.
Clients with Workcover or TAC funding
Please be aware that Workcover and TAC will not pay for non-attended sessions. Therefore, if you fail to attend your appointment, or cancel without giving the required amount of notice, you will be invoiced personally for the full fee.
Outstanding fees
An invoice will be issued for any outstanding fees, payable within 14 days. A payment arrangement
can be negotiated with the Practice Manager or your treating practitioner if financial problems
arise. Unpaid accounts will be sent to a debt collection agency and you will also be responsible to
meet the cost of the debt collection fee.
Any difficulties? Just ask.
Sometimes clients find themselves in unforeseen circumstances in which it may be difficult to
pay bills. We do not wish to make life any harder for people in this situation. If you have
problems paying an account, please contact the Practice Manager or your treating practitioner
to discuss your situation and negotiate a payment plan. This saves embarrassment and
misunderstanding and prevents us from being diverted from our philosophy to assist our
clients to enhance their wellbeing, build life skills and fulfil their potential.
Charter for Clients of Psychologists
Is available here or asking for a copy at reception.
Your agreement
Please complete the below form confirming you have read and understood the above Consent Form and Fee Policy. And agree to these conditions for the counselling service provided by the practitioner at Crookes Counselling & Consulting Service.
Please Note: If, after reading this form you are at all unclear about any of the information provided, please speak to the psychologist prior to your appointment.
