Client Consent Form

Client Consent Form

Please select age: *

Under 16 years of age16 years and over

Client First Name: *

Client Surname: *

I, Parent/Legal Guardian name:

have read and understood and accept the Terms and Conditions (https://www.hallpsychology.com.au/terms-and-conditions.html) and give consent to: *

to liaise with the following people involved in my care about my psychological treatment. Please identify the people you consent for us to contact (it is a requirement of Medicare that we provide written reports to your GP):

to liaise with the following people involved in my/his/her care about my/his/her psychological treatment. Please identify the people you consent for us to contact (it is a requirement of Medicare that we provide written reports to your GP):

General Practitioner name

Medical Specialist name

Insurance Company name

Insurance Claims Manager name

Rehabilitation Company

Rehabilitation Coordinator name

Physiotherapist

School Counsellor / Year Coordinator name

Parent / Guardian(s) name

Parent / Guardian(s) number

Emergency Contact name

Emergency Contact number

I understand and accept that personal information gathered by my psychologist will remain confidential and secure except when:

1. Failure to disclose the information would place you or another person at risk of harm,*

2. It is subpoenaed by a court,

3. My prior approval has been obtained to provide either a written report or to discuss the material with an external professional or agency.

*Psychologists are considered “mandatory reporters” and are required by law to report to the statutory regulatory body if they suspect (using their professional judgement and training), on reasonable grounds, that a child or young person is at risk of harm (i.e. physical, sexual or emotional abuse or neglect).

*

Before we proceed with your appointment, I want to inform you about an important aspect of how we document our consultations. We utilise a note taking tool called Heidi to accurately and efficiently capture the details of our discussions and the outcomes of our appointments. Heidi ensures that we can focus more on our conversation and less on manual note taking, enhancing the quality of care you receive. Only your clinician will have access to your information. Heidi is compliant with the Australian Privacy Principles and the Privacy Act. Their information management systems are ISO27001 accredited for data security. Your data protection is our top priority. All data is encrypted, securely and confidentially stored on servers located within Australia to comply with local jurisdiction requirements. Only data will be collected that is essential for providing services. Heidi restricts the disclosure, retention, and use of all data, ensuring it is safeguarded. Conversations are transcribed simultaneously while they happen, meaning no recordings are ever stored. Notes that a clinician saves at the end of each appointment will be copied and added to your Electronic Health Record in your clinician’s secure Practice Management System, as standard. The information is then deleted from Heidi. By signing this form you are agreeing to allow your clinician to use Heidi during your consultations.

*

I consent to Hall Psychology and Coaching using and sharing my de-identified and anonymous personal information and questionnaire results for research. I understand that I may withdraw my consent at any time although if my personal information has been used in a project or incorporated in a database it may not be possible to remove my personal information. I consent to Hall Psychology and Coaching using and sharing my personal information to contact me about participating in future research projects.

I consent to receiving emails from Hall Psychology and Coaching with information about services, promotions, special offers, news and events.

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Date *

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