INFORMED CONSENT FOR PSYCHOLOGICAL SERVICES

Nature and purpose of the Psychological Service

As part of providing a psychological service including assessments and counselling to you, Trish Thomas will need to collect and record personal information pertaining to you. This information is a necessary part of the psychological assessment and treatment that is conducted.

Psychotherapy varies depending on the personalities of the psychologist and patient, and the particular problems you bring forward. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.

Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow. If you have questions about my procedures, we should discuss them whenever they arise. You are able to cease therapy with myself at any time. If you feel uncomfortable with what is happening in a session you may request for the session to cease at any time.

Access to your information

As part of providing psychological services, relevant personal information to the current situation will be collected and recorded. The information will assist in providing an appropriate and thorough service. Information will be stored in a secure location. I am required to keep your file for a minimum of 7 years, or if you are under the age of 18 at the time of treatment, until you are 25 years of age. You may access the information in your file on request, subject to the exceptions in the National Privacy Principles.

Confidentiality and Privacy (For further information please see Privacy Policy for the Management of Personal Information)

All personal information gathered by the psychologist during the provision of psychological service will remain confidential and secure except when:

it is subpoenaed by a court, or disclosure is required or authorised by law; or
failure to disclose the information would place you or another person at risk of harm; or
given your prior approval, or consent of a parent or guardian who is legally authorised to act on your behalf in order to provide a written report to another professional or agency, or discuss information with another person e.g., parent or employer; or
you would reasonably expect your personal information to be disclosed to another professional or agency and disclosure is directly related to the primary purpose for which it was collected such as to inform your GP of treatment and progress; or
clinical consultation with another professional is required to provide better clinical services (identifying details will remain confidential).

If during the course of your work with the Trish Thomas, she becomes aware of risk to someone’s life, health, or wellbeing, she is required by policy of the state and federal governments to report the matter to the appropriate agencies.

Session Fees (please see Fee List - fees will be reviewed in January each year)

My agreed fee is $220 per session (one hour duration) and is payable at the time of consultation.

Session fees to be charged to a third party:

Third Party Name: __________________________________________________

Contact Person: __________________________________________________

Contact Details: __________________________________________________

Approval Number: ________________________________________________

Private Health Insurance

Some health insurance policies cover counselling depending on the policy. Please check with your insurance company as to what cover you are eligible.

Medicare Rebates

Under the Medicare Benefits Schedule (Better Access), Medicare rebates are available to clients with an assessed mental disorder. Medicare rebates are accessed with a Mental Health Treatment Plan and referral from a medical practitioner, psychiatrist, or paediatrician. The rebate is limited to 10 sessions per calendar year and only available with a valid referral. Please note the maximum number of sessions per referral is 6 and rebates will not be given beyond the number stated on the referral.

Cancellation Policy

If for some reason you need to cancel or postpone your appointment, please give at least 48 business hours’ notice - a $220 fee will be charged for all No Shows to an appointment. This no show or late cancellation fee will need to be paid on or before your next visit. Please make every effort to notify the practice if you are unable to attend an appointment - there are often other client’s waiting for appointments, and it would be appreciated if other clients could be given the opportunity to come in. To cancel or rearrange an appointment, please call 03 7068 5808.

Emergency

In case of emergency, please go to the emergency department of the nearest hospital. For further information refer to the website for your local health district. For out of hours phone support, you may find it helpful to call Lifeline on 13 11 14.

Consent

I, (print name) ________________________________________ have read and understood the above consent form provided by Trish Thomas and have had the opportunity to have any questions I may have about it answered. I agree with the psychological service provided and the associated fee I am required to pay.

Signed (Client/ Parent*/ Guardian*)

Print name

Date

___________________________________________

_____/_____/_____

*For client’s unable to give informed consent.

Trish Thomas Psychologist

Info

Qualifications and Experience

Education

Specialisation and Services

Modalities

Patient Focus

Services