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):

General Practitioner name

Medical Specialist name

NDIS Support Coordination Company name

NDIS Support Case Coordinator 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).

*

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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