Consent form for psychological services

All information is private and confidential.

Your full name*

Is there another name you’d prefer us to address you as?

Age*

D.O.B*

Address*

Address Line 2

ZIP/Postal Code*

State / Province / Region*

Your phone*

Your email*

Medicare Number

Reference Number (IRN)

Expiry Date

Concession/ Health Care Card*
YesNo

Concession/Health Care Card Number*

Emergency Contact*

Emergency Contact Phone Number*

Please identify your Gender*

Your Preferred Pronoun*

Do you identify as Aboriginal, Torres Strait Islander, Aboriginal and Torres Strait Island?*

YesNo

If so, please specify.*

Are you under the age of 18?*

YesNo

Parent/Guardian Name*

Parent/Guardian D.O.B*

Parent/Guardian Address
*
Address Line 2

ZIP/Postal Code*

State / Province / Region*

Parent/Guardian Phone*

Parent/Guardian Email*

Parent/Guardian Medicare Number

Parent/Guardian Reference Number (IRN)

Parent/Guardian Expiry Date

Are you/is the client taking medications?*

YesNo

If yes, please list medications*

Referring GP and Practice Details

Have you seen a mental health professional in the past?*

YesNo

If yes, please provide details in the space below.*

Do you consent to Crystal Clear Psychology Solutions contacting the above mentioned professional for the purpose of information gathering in order to provide assessment and treatment?*

YesNo

How did you find this service?*

WebsiteReferralGoogle SearchDoctor's OfficeFacebookOther

If other, please detail*

Briefly describe your reason for coming to see Crystal Clear Psychology Solutions*

Confidentiality

As part of providing a professional psychological service to you, Crystal Clear Psychology Solutions will need to collect and record personal information from you that is relevant to your current situation. All personal information gathered by Crystal Clear Psychology Solutions 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. e.g. a lawyer; or b. discuss the material with another person, eg. a parent or employer.

4. To provide a letter to your GP for the purpose of outlining your attendance in therapy and an outline of treatment modalities used, as per the requirements of Medicare.

All of the above exceptions to confidentiality are extremely rare, but it’s important for you to be aware of these limitations of confidentiality under exceptional circumstances.

Telehealth

Crystal Clear Psychology Solutions offers telehealth psychological services via phone or video.

You have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of your medical information for in-person psychotherapy. Any information disclosed during your therapy, therefore, is generally confidential. There are risks unique and specific to Telehealth, including but not limited to, the possibility that our therapy sessions or other communication by the therapist to others regarding my treatment could be disrupted or distorted by technical failures or could be interrupted or could be accessed by unauthorized persons.

Coviu is a secure (encrypted) video conferencing system, and is virtually impossible for anyone to intercept and decrypt the video transmission between two people. Please see the Coviu website (https://www.coviu.com) for more information on Coviu privacy policies. Crystal Clear Psychology Solutions is not responsible or liable for compromised Coviu communication between you and your psychologist. It is very important you keep your information secure and private, and routinely check your computer system for viruses and trojans.

Recording of counselling sessions

Recording of sessions is a violation of our confidentiality agreement and is strictly prohibited. Management reserves the right to suspend all counselling services to any client who records or retransmits any part of a counselling session.

Assessments

Crystal Clear Psychology Solutions will utilise NovoPsych to administer specific assessments when utilising telehealth options. NovoPsych is an Australian based psychometrics software company. You will receive a direct email from NovoPsych and be able to complete the assessment online accordingly. Please visit NovoPsych’s website if you require further information – https://novopsych.com.au.

Fees and Financial Consent

The cost of a one-hour psychology session is $150.00 and payable upon completion of the appointment. With a valid GP Referral and Mental Health Care Plan, you may receive a rebate of $89.65 per session for up to 10 sessions per calendar year.

All fees are payable by the end of the session by Bank Transfer, Eftpos or Credit. An invoice will be supplied at the completion of the session. The Australian Psychological Society’s recommended fee schedule for a one-hour psychology session is $280.00, and Crystal Clear Psychology Solutions offers a reduced rate. Rates may be subject to change.

Please note, Open Arms (VVCS), DVA, WorkCover, and EAP providers have their own fees applicable and no gap fees are applied to the client. For NDIS self-managed plans, a fee of $180.00 is applicable per one-hour psychology appointment. Please refer to our fee schedule for more information on applicable fees with Crystal Clear Psychology Solutions.

Missed Appointment Fee

Due to the high demand for appointments, this practice has a Missed Appointment Fee. All clients receive a text 48 hours prior to their appointment. Please notify us at your earliest convenience once you have received the text should you wish to reschedule or cancel, please phone 0476 758 096. It is essential that you cancel appointments with enough notice to be able to offer the appointment to another client on the waitlist. Any appointments cancelled within 24 hours of the scheduled appointment will be charged at the full fee rate. Medicare or other parties do not cover the costs of non-attendances or late cancellations. The cancellation fee must be paid before any future appointments are scheduled, and within 24 hours. Your understanding is appreciated.

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

YesNo

Full Name or Parent/Guardian (if under the age of 18):*

Today’s Date*

Signature*

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