CLIENT CONSENT
To be completed by client or parent/guardian for minors.
I understand that: The information Hourglass Psychology collects from me is required as part of my engagement in psychological counselling. Assessment and treatment will explore a range of personal information (e.g., my background, relationships, current functioning, physical and psychological health, and substance use). It is not compulsory to provide personal information, however, a thorough understanding of me and my history enables the psychologist to deliver informed and relevant service.
CONFIDENTIALITY
Information collected during the course of assessment and treatment will remain private and confidential, except where:
· I provide authority to exchange information with a third party
· There are concerns for mine or someone else’s safety
· Disclosure is subpoenaed by a court or otherwise required by law
- If information is required to be disclosed, Hourglass Psychology will seek my consent or input if it is reasonable to do so.
- When accessing a Mental Health Care Plan, I agree to information being shared with my referring doctor in respect of treatment and management.
- My psychologist may consult with a clinical supervisor or peer psychologist about my treatment. Unless otherwise agreed with me, no personally identifying information is disclosed during the course of consultation.
- Electronic records are kept in a secure format for the duration as required by law. Hourglass Psychology will take reasonable steps to protect my information from unauthorised access, modification or inappropriate disclosure.
ACCESS TO YOUR INFORMATION
I have a right to request access to my personal information and to make corrections. Hourglass Psychology may discuss with me the appropriate forms of access, including a summary report. Any such request must be in writing and authorised by me, or where applicable, by the consenting parents, or subpoenaed by a court.
URGENT MEDICAL ATTENTION
In the unlikely event of sudden injury or illness I consent to medical treatment being given if the emergency contacts provided at time of my registration are uncontactable.
CONSENT FOR CHILDREN
A signature of consent from one parent or guardian is deemed to indicate family consent from all parents or guardians. In a situation of separation/divorce, dual consent is required, unless a court order is in place which clearly stipulates sole custody. A copy of the relevant extract from such an order will be required to be provided.
In the event one parent or guardian does not consent or subsequently withdraws their consent, the Psychologist is unable to continue working with the child unless a court gives authorisation to continue.
The Psychologist is able to work with a parent to support them in their time of family difficulty.
TELEHEALTH (WHERE REQUIRED AND APPROPRIATE)
- At the commencement of each session, the Psychologist will require me to provide my location and will ask for any revised details of emergency contacts in the event of an ‘at risk’ situation or emergency.
- I am aware that: the privacy of communication via the internet or a mobile device is potentially vulnerable and limited by the security of the technology. The psychologist will use an appropriate and secure online service to deliver mental health services.
- I am aware that: email communication is not secure and should contain minimal personal information.
- I am responsible for any costs incurred in relation to the provision of my own software, hardware and data usage associated with this Telehealth service.
- The Psychologist will not make recordings of sessions or use material from sessions for purposes other than delivering a service to me. The Psychologist will seek my written consent if they wish to use material for other purposes.
- I am required to respect the privacy of the Psychologist by agreeing not to make recordings of our sessions and not to use materials from sessions for purposes other than therapy. If I wish to record sessions or use session material for other purposes, I must seek consent of the Psychologist.
NO-SHOW, CHANGES AND CANCELLATION
In the event of a no show, or cancellations and changes made with less than 24 hours notice of my appointment, 100% of my session fee will be charged. In cases where less than 48 hours’ notice is given, 50% of the session fee will be charged. This applies to Telehealth appointments also. Where applicable, the cancellation fee is processed using the Credit/Debit Card details I provided to secure my booking.
I understand that the treatment I receive from Hourglass Psychology may not provide the expected results although the treatment is carried out with due professional care.