Consent form (adult)

Client Consent Form (adult)

First Name *

Preferred Name

Last Name *

Date of birth *

Gender

Pronouns

Email Address *

Street Address *

Suburb *

Postcode *

Mobile number (no spaces) *

Medicare number (no spaces) *

Medicare individual reference number *

Do you have a Health Care Card or Pension Card? *

Health Care Card/Pension Card Number *

Emergency Contact: Full name *

Emergency Contact: Relationship to client *

Emergency Contact: Phone number *

For parents / guardians to receive the Medicare rebate, please complete the Alternative claimant details below:

Alternate claimant name (who receives the Medicare Rebate)

Alternative claimant date of birth

Alternative claimant Medicare number

Alternative claimant Medicare card individual reference number

Consent information

Please read through the information detailed below and indicate your consent by signing at the end of the form.

Positive Psychology is committed to protecting your privacy. This relates to how we:

Collect your information
Use/share your information
Keep your information confidential
Storing of your personal information
Payment and cancellation fee

Collect your information

In order to provide you with the highest standard of psychological service, this practice will need to collect and record personal information from you that is relevant to your current situation.

Personal information is only collected when it is knowingly and voluntarily submitted, including:

When contacting us to schedule your initial appointment
Information that you provide by filling in forms (e.g. client consent form) or when you communicate with us via our website (e.g. online enquiry)
The information your psychologist collects as part of the therapy process.

Use/share your 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 therapy goals (e.g. your GP, specialist, parent, WorkCover, etc.). Please note that if you intend to claim rebates from Medicare or another organisation (such as WorkCover or TAC), your psychologist must provide summary reports to external agencies regarding your treatment progress. Under the Medicare scheme these reports will normally be sent to your GP. Positive Psychology may use your personal information to:

Collect payment and deliver statements or invoices.
Reports or letter to third parties.
Provide you with information requested from us relating to our products or services (you can unsubscribe at any stage).
Provide specific information to other medical, allied health, legal or other third party as appropriate or legally required.
As a client you are entitled to access to the information about you kept on file, unless the relevant legislation provides otherwise.

Keep your information confidential

Highly personal information may be shared during sessions/therapy and it is important for the success of treatment that you have confidence in your psychologist’s ability to manage your records responsibly. All information provided to the Positive Psychology will remain confidential except where:

Failure to disclose the information would place you or another person at serious and imminent risk of harm (including when required by mandatory reporting laws).
Prior approval has been provided by the client.
Documentation is subpoenaed by a court.
In exceptional circumstances, personal information may also be released if we have reason to believe that doing so is necessary to identify, contact or bring legal action against anyone interfering with our rights, property or clients.

Privacy in online communications

Some clients may choose to have consultation via Telehealth. The privacy of any form of communication via the internet or a mobile device is potentially vulnerable and limited by the security of the technology. At Positive Psychology we use Coreplus, which is a web-based software which enables our practitioners to make video calls with clients. We have chosen Coreplus as our preferred software for its key advantages, including:

It is more stable.
There is no need for our clients to purchase software to use it.
Coreplus provides end-to-end encryption for data security and is promoted as facilitating practitioner compliance.

Please be aware that email communication is not secure and should contain minimal personal information. Positive Psychology tends to use email for administrative purposes such as setting up appointments. Invoices and receipts can be emailed as a word document attached to an email, and the word document will be protected by a password that we agree together.

We will provide you with suggestions to help you protect your own online privacy for our sessions.

Please be aware that you are responsible for any costs incurred in relation to the provision of your own software, hardware and data usage associated with this telehealth service.

Locations (Face to face and telehealth services)

All face-to-face sessions will take place at one of Positive Psychology’s private practice locations or at your residence in the case of a home visit. When engaging in telehealth because you may be in varied locations for each of our video conferences , we will require you to provide your location to your practitioner at the commencement of each session.

Storing of your personal information and health records

Positive Psychology will take reasonable technical and organisational precautions to prevent the loss, misuse or alteration of your information. All personal information you provide will be stored on our secure servers. Additionally, our employees and the contractors who provide services related to our information are obligated to respect the confidentiality of any personal information held by us.

Because the transmission of information via the internet is not completely secure, we cannot guarantee the security of data sent to us electronically. Therefore, the transmission of such data is at your own risk.

Electronic records and paper records are kept in secure storage.

Use of therapy session materials

At Positive Psychology your practitioners will not make recordings of your sessions or use material from your sessions for purposes other than delivering a service to you. Our practitioners will seek your written consent if they wish to use material for other purposes (such as consultation with colleagues).

We ask you to respect your practitioner’s privacy by agreeing not to make recordings of your sessions and not to use materials from your sessions for purposes other than therapy. If you wish to record sessions or use session material for other purposes, you must directly seek the consent of your practitioner to do so.

Code of conduct

All individuals within our premises must treat staff and clients with courtesy and respect at all times. Aggression, yelling and violence will not be tolerated.

Cancellation policy and payment

When you make an appointment to see one of the psychologists, we reserve the whole hour for you. If for some reason you need to cancel or postpone your appointment, you must provide 24-hour notice. This is to allow time to offer the appointment to another client who may be on a cancellation list waiting for an appointment. A cancellation fee must be paid before rebooking if there is insufficient cancellation notice or non-attendance to an appointment. Please note that Medicare or health insurance rebates are not applicable to cancellation fees.

All clients are required to make full payment for their session on the day of consult (unless other payment arrangements have been made). For clients using private health funds, please check if your policy covers psychology. We do not provide onsite rebates for private health funds, however we can provide you with an invoice for you to claim a rebate directly from the private health fund provider.

Please confirm that you have read, understood and agree to these conditions, please sign below:

Signature *

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