Client Consent Form

Psychological services

As part of providing a psychological service to you, JLS Psychology Services needs to collect and record personal information 
from you that is relevant to your situation, such as your name, contact information, medical history, and other relevant information as part of providing psychological services to you. This collection of personal information will be a necessary part of the psychological assessment and treatment that is conducted.


Purpose of collecting and holding information

Your personal information is gathered as part of your assessment and treatment and is kept securely. In the interests of your privacy, it is used only by your psychologist and the authorised personnel of the practice as necessary. Your personal information is retained to document what happens during sessions and enables the psychologist to provide a relevant and informed psychological service to you. A more detailed description is provided in the practices "Privacy policy for management of personal information", which can be obtained by contacting our office. The privacy Policy contains information about how to access and seek correction of your personal information, and how to lodge a complaint about our management of your personal information.


Disclosure of personal information

All personal information gathered by the psychologist during the provision of the psychological service will not be disclosed except when:

    1. it is subpoenaed by a court; or,

    2. failure to disclose the information would in the reasonable belief of your psychologist, place you or another person at     serious risk to life, health, or safety; or,

 3. your prior approval has been obtained to
        a) provide a written report to another professional or agency, e.g., a GP or a lawyer; or,
        b) discuss the material with another person, e.g., a parent, employer, or health provider; or\,

        c) disclose the information in another way; or,

        d)  you would reasonably expect your personal information to be disclosed to another professional or agency (e.g., your GP) and disclosure of your information to that third party is for a purpose which is directly related to the primary purpose for which your information was collected; or,

        e) disclosure is otherwise required or authorised by law.

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.


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, the psychologist may not be able to provide the psychological service to you. You may request to be  anonymous or to use a pseudonym unless it is impracticable for your psychologist to deal with you or if your psychologist is required or authorised by law to deal with identified individuals. In most cases it will not be possible for you to be anonymous or to use a pseudonym, however, if your psychologist agrees to you being anonymous or using a pseudonym, you must pay consultation fees at the time of the appointment.


Access to client information

At any stage you are entitled to access your personal information kept on file, subject to exceptions in the relevant legislation. The psychologist may discuss with you, different possible forms of access.


Fees

The cost of a consultation (50 minutes) $240.00, which is payable prior to your appointment. To secure and confirm your appointment a valid credit or debit card is required or your appointment will be cancelled. 

If you fail to attend or cancel your appointment less than 24 hrs prior a cancellation fee of $240.00 will be charged on the credit/debit card provided. Additionally, if you fail to pay for your appointment on the day, the cost of the session will be recovered by charging the credit/debit card you provide.

Payments organised though third parties, must be approved prior to appointments and may have an out-of-pocket cost. To discuss your options, please contact your case manager/insurance company. Accounts will remain the responsibility of each client and clients will be required to cover all reasonable costs incurred should the agency withdraw or later refuse to pay such costs, for any reason. Hence we require a valid credit or debit card to secure your appointment at the time of booking. No charges will be incurred unless it is to cover appointments attended or cancellation fees, if not covered by the third party.

Additional report writing, professional letters, assessments, conferences, meetings, etc, are charged accordingly by the hour with fees based on the nature of the report and level of expertise required. To enquire, please discuss with the psychologist.


Cancellation Policy

If, for some reason you need to cancel or postpone your appointment, please give reception minimum 48 hours’ notice by calling, texting or via email.

Cancellation Fees: $240.00 for under 24 hours notice I  $100.00 for 24 hrs>48 hrs notice.

Charter for Clients of Psychologists

https://psychology.org.au/getmedia/5fb479bb-4ab8-49f3-a9eb-1a76a3779ef4/aps-charter-for-clients.pdf


Consent

I,

give consent for Ms Smoker to provide psychological services to:

I have read and understood this Consent Form. I agree to the above conditions and the psychological service provided by Ms Smoker at JLS Psychology Services.

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