CLIENT ENGAGEMENT AGREEMENT & CONSENT FORM

Welcome to The Mind Body Practice. We look forward to working with you to help you achieve the life you want. Before we get started, please carefully read and complete this form, which sets out:

your details
the service we'll provide
the terms on which we agree to provide those services
financial consents and authorisations
confidentiality of information we collect, keep and disclose
information consents and authorisations

All information will be kept strictly confidential in accordance with our Privacy Policy, which is available on our website www.mindbodypractice.com.au or by requesting a copy from us.

These terms, consents and authorisations will also apply to any future services that we may provide to you. We won’t issue a new copy of these terms of consents unless they have changed since our last engagement or you request it.

Please note, this form is to be completed by the client. If the client is child or adolescent, the form can be completed by the parent.

Completing this form is likely to take 10-20 minutes, and saves time at your first appointment. If you have any questions, please do not hesitate to contact the administration team on 80917867 or admin@mindbodypractice.com.au.

Psychological services
Our treating team offer a research-based approach to the delivery of psychological services that support individuals facing difficulties related to wide range of mental health and relationship difficulties. We tailor our services for children, adolescents, adults and families.

The services we agree to provide under this agreement are set out in our current Schedule of Fees for Psychology Services. We reserve the right to amend our Schedule of Fees on one month’s notice to you, to be delivered via email. We’ll discuss the nature and purpose together with their potential effects as part of providing these psychological services to you.

Please note that we do not provide services or offer treatment for:

Work capacity assessment.
or provide reports for medico-legal purposes.

Contact
You can contact the practice by telephone between 10AM and 8PM Monday to Thursday & 10AM and 6:30PM on Friday. Limited reception services are available where you may leave a message and we will return your call by the next business day.

Please note that The Mind Body Practice does not provide emergency or crisis services. If you require immediate assistance, please call 000 or phone Lifeline on 13 11 14 for urgent counselling.

Unless you advise us of any specific alternative contact arrangements, we’ll contact you by phone, email and text according to the details you’ve provided us with.

Please ensure you have provided a private email address as confirmations of appointments, payment receipts or statements of Medicare rebates will be sent automatically to email provided. Forms, questionnaires and homework resources may also be sent via email attachments. Please note, it is a practice policy to not discuss personal content via emails. As such, any emails containing such information will not be responded to electronically. Rather, the content will be discussed as part of treatment in session. All correspondence forms a part of your clinical records.

Email confirmations of new or rescheduled appointments are sent via email. As a courtesy, automated SMS text message reminders are sent at 8:30AM two days prior to your appointment. Please do not respond to this reminder as this is an automated service that comes from a computer. If you need to cancel or reschedule your appointment call or email the practice as soon as possible.

Payments and rebates
Our current Schedule of Rates details the cost of a standard 50-minute consultation, which are significantly lower than those recommended by the Australian Psychological Society (APS) (currently set at $311.00). Fees are payable at the end of the session by credit or debit card via our EFTPOS terminal.

If you have a Mental Health Care Plan and have provided the practice with written consent (see below), your rebate will be processed after the session with Medicare depositing the funds in your nominated bank account within three business days. If you have health insurance, you may be eligible for a rebate. Contact your health insurance provider for more information. If payment is covered by a third party, such as an EAP provider, process of payments will be discussed at the start of treatment.

Outstanding accounts may be referred to a debt collection agency or solicitor and you will be liable to pay any costs we incur or become liable to pay for the collection of such unpaid amounts, including but not limited to debt collection fees, charges and commissions and legal fees and costs on a full indemnity basis.

Cancellation and late arrival policy
To ensure all our patients have the opportunity to receive the care that they need, you can cancel or postpone your appointment up to 24 business hours before the scheduled time without incurring a cancellation fee.

This means that if you have an appointment booked on a Monday or after a long weekend, we will require notice of any changes a minimum of 24 business hours prior to your appointment for rescheduling & cancellations. This then allows our Admin Team some time to contact those who are on the waitlist for an appointment in the event you are no longer available to attend yours.

Cancellations can be made by sending us an email to admin@mindbodypractice.com.au or by calling the practice phone on 02 8091 7867 and speaking with a member of our Admin Team or leaving a voicemail.

Appointments missed or cancelled within 24 hours of the scheduled appointment time will be charged a cancellation fee equal to the full session fee (or if the session has been funded by your EAP provider, the session will be forfeited and you will be charged directly). Please note, rebates cannot be claimed from Medicare for cancellation fees.

The practice is committed to starting every session on time, so please understand that every session will need to end at the scheduled time to ensure that no clients are left waiting.

Termination of treatment
You may participate or decline to participate in the treatment we propose or withdraw from the treatment in future by telling your therapist. Cancellation fees apply as set out above. Your psychologist will discuss with you any potential consequences of declining or withdrawing from treatment.

We may terminate your treatment if it becomes clear you’re not benefiting from the services, if we’re no longer able to deliver the services or if we form the view that we’re not competent to deal with your problem or situation. If we terminate the services, we’ll explain why and take all reasonable steps to safeguard your ongoing welfare, including by making reasonable arrangements for another service provider to assist you.

Confidentiality
As part of providing psychological services including assessment, diagnosis, treatment, and care to you, The Mind Body Practice needs to collect and record relevant personal information from you, such as your name, contact information, medical history and other relevant information. This collection of personal information is a necessary part of our psychological assessment and treatment of you. We avoid undue invasion of privacy in collecting information by only collecting information that is relevant to the service we are providing.
This section sets out a summary of our commitment to maintaining the confidentiality of information we receive from you, including exceptional situations where your confidentiality may not be protected.

Purpose of collecting and holding information
We gather your personal information as part of our assessment and treatment of you. We may gather information from you or by other lawful and fair means, such as from other people (for example, from your GP or My Health Record) with your consent. If you don’t give us consent to collect information from others, this may impact on the service you receive, as your psychologist is able to provide the best service with complete information.

Your personal information is kept securely and, in the interests of your privacy, used only by your psychologist and the authorised personnel of the practice (as necessary). Security of your personal information is ensured by storing the information in secure electronic records systems, including Halaxy, Docusign, Jetforms and Mailchimp platforms and locked filing cabinets.

We keep your personal information to keep records of what happens during our sessions with you. This enables your psychologist and any other members of your treating team to provide you with a relevant and informed psychological service. We may also keep your information for administrative purposes, such as record keeping for the purpose of the Medicare Benefits Scheme and processing payments and Medicare rebate claims. We keep your personal information for a minimum of 7 years after our last contact with you (or if you’re under 18, until you’re 25).

We may also use your personal contact information to communicate with you, including sending you our newsletter and other marketing materials (if you’ve consented to receiving those).

Accessing your information
You can ask for access to your personal information at any stage. Reasonable requests for access will be granted unless an exception in the relevant legislation applies. Your psychologist may discuss with you different ways you can access your personal information.

Disclosure of personal information
We only disclose personal information necessary for the provision of services to you and then only to people required to have that information.

All personal information gathered by your psychologist while working with you will remain confidential, except in the following circumstances:

The information is subpoenaed by a court or The Mind Body Practice is otherwise required or authorised to disclose the information by law.
If The Mind Body Practice forms the reasonable belief that disclosure of your information is necessary to protect you or another person from serious risk to your or their life, health or safety.
If you have previously authorised The Mind Body Practice to:

provide a written report to another professional or agency (for example, your GP or lawyer); or
discuss your personal information with another person (for example, with your parent, employer, health provider or third-party funder); or
disclose the information in another way; or
disclose your personal information to another professional or agency (for example, your GP or another specialist) in relation to the primary purpose for which your personal information was collected.

All psychologists are required by the Psychology Board of Australia to engage in professional supervision to maintain registration. This may involve discussing clients – including you – in a non-identifiable way.

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.
Your rights as a client of a psychologist are available through the APS Charter of Clients of Psychologists, available through The Mind Body Practice website.

Research
The Mind Body Practice conducts research to improve our understanding of treatment of psychological or health difficulties. We also engage in continuous quality improvement programs.

Your information may be used in a de-identified form in our research and programs. Your information will be kept strictly confidential and will be treated in accordance with our Privacy Policy.

There may also be opportunities for you to participate in particular research projects. We will let you know about research that might be suitable for you if it arises during your treatment. If you do not wish to be approached for participation in research, please let us know. Participation in these projects is entirely voluntary and opting out will not affect the services we provide to you in any way.

Consequence of not providing personal information
If you do not wish for your personal information to be collected in a way anticipated by this letter or the Privacy Policy, we may not be able to provide the services to you.

You can ask to remain anonymous of use a pseudonym and if it’s practicable and permissible by law, we’ll use that.

Please note that in most cases it will not be possible for you to be anonymous or to use a pseudonym as the law requires us to deal with identified individuals, so if you don’t provide us with your personal information we won’t be able to provide the services to you.

Telehealth Sessions Consent

Prior to starting video-conferencing services, we discussed and agreed to the following:

There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions.
Confidentiality still applies for telepsychology services, and nobody will record the session without the permission from the other person(s).
You consent to the use of Coviu/Halaxy as a telehealth platform. Please read through their privacy policy. If you do not consent to the use of Coviu/Halaxy, please inform your clinician and the session can be conducted over the telephone.
We need a back-up plan (e.g. phone number where you can be reached) to restart the session or to reschedule it in the event of technical problems.
In this case, your clinician will conduct the session via telephone and will ring the number listed on your consent form.
You need to use a webcam or smartphone during the session.
It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.
It is important to use a secure internet connection rather than public/free Wi-Fi.
It is important to be on time. If you need to cancel or change your tele-appointment, you must notify the psychologist in advance by phone or email.
If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telepsychology sessions.
You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment.
By completing this form, you agree to the assignment of the Medicare benefit directly to the provider, The Mind Body Practice, when sessions are bulk billed.
If you receive an email from us, please type your name to sign the ‘consent to bill Medicare’ form. This enables us to bill Medicare for the service. There is no cost to you from The Practice.
We need a safety plan that includes at least one emergency contact and the closest hospital to your location, in the event of a crisis situation. You agree to disclose your location at the start of each session to ensure safety.
You agree that if you Psychologist is worried about your safety and session were to be disconnected, the Psychologist will call your emergency contact to check up on you.
You agree to abide by the safety plan outlined below.
As your Psychologist, I may determine that due to certain circumstances, telepsychology is no longer appropriate and that we should resume our sessions in-person.

More information
A more detailed description of how we collect, use, maintain and disclose your personal information is available in the practice’s “Privacy Policy" , which can be obtained by contacting admin@mindbodypractice.com.au or on our website.

The Privacy Policy also sets out:

how you can access and seek correction of your personal information;
how we will store your personal information including the use of electronic platforms such as Halaxy, Docusign, Jetforms and Mailchimp;
how to lodge a complaint about our management of your personal information;
how we’ll deal with a complaint, and;
whether we’re likely to disclose your information overseas (and if so, where).

I have read and understood this Consent Form. I agree to the above conditions for the psychological service provided by The Mind Body Practice as set out in these Terms of Service.

Please note, this consent is to be signed by an adult client or their parent/guardian.

Sophie White Psychologist (Provisional)

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