TELEHEALTH CONSENT FORM

Consent for a counselling telehealth service

As part of providing a counselling service to you, the counsellors and staff at ALY’S PLACE Research-Based Counselling for Couples and Individuals need 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 therapeutic assessment and treatment that is conducted. A detailed description of how your personal information is managed, how you can access your personal information, and how to lodge any concerns or complaints about this service or how your personal information is managed must be provided to you by your health professional on request.

Disclosure of personal information

Personal information gathered as part of this service will remain confidential except when:

1. it is subpoenaed by a court; or

2. failure to disclose the information would 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, eg. a parent, employer or health provider; or c) disclose the information in another way; or

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

5. disclosure is otherwise required or authorised by law.

Use of therapy session materials

ALY’S PLACE Research-Based Counselling for Couples and Individuals staff and counsellors will not make recordings of our sessions or use material from our sessions for purposes other than delivering a service to you. We will seek your written consent if we wish to use material for other purposes (such as consultation with colleagues or therapy evaluation). We ask you to respect the privacy of ALY’S PLACE Research-Based Counselling for Couples and Individuals staff and psychologists by agreeing not to make recordings of our sessions and not to use materials from our sessions for purposes other than therapy. If you wish to record sessions or use session material for other purposes, you must seek our consent to do so.

Provision of a telehealth service

Where appropriate the service may be provided by telephone or videoconferencing. You are responsible for the costs associated with setting up the technology needed so you can access telehealth services. ALY’S PLACE Research-Based Counselling for Couples and Individuals will be responsible for the cost of the call to you and the cost associated with the platform used to conduct telehealth services. To access telehealth consultations you will need access to a quiet, private space; and the appropriate device, i.e. smartphone, laptop, iPad, computer, with a camera, microphone and speakers; and a reliable broadband internet connection. Because you may be in varied locations for each of our videoconferences or phone calls, we will require you to provide your location at the commencement of each session. The privacy of any form of communication via the internet is potentially vulnerable and limited by the security of the technology used. To support the security of your personal information this practice uses encrypted Zoom services (no download needed – https://zoom.us/) which is compliant with the Australian standards for online security and encryption.

Limitations of telehealth

A telehealth consultation may be subject to limitations such as an unstable network connection which may affect the quality of the counselling session. In addition, there may be some services for which telehealth is not appropriate or effective. Your counsellor will consider and discuss with you the appropriateness of ongoing telehealth sessions.

Fees

The cost of a couples consultation (approximately “90” minutes) and an individual consultation (approximately “60” minutes) are in line with the industry standards for registered counsellors in Australia. The fees are $150 for 90-minute online sessions and $100 for 60-minute online sessions. Your counsellor will discuss with you your eligibility for private health rebates or other compensable funding.

Cancellation Policy

If you need to cancel or postpone your appointment, please give the counsellor at least 24 hours notice, otherwise you will be charged a cancellation fee of $50.

Australian Counselling Association (ACA) Code of Ethics

ALY’S PLACE Research-Based Counselling for Couples and Individuals follows the ACA Code of Ethics that explains your rights as a client of a registered counsellor and is available here.

Consent to receive counselling services by telehealth

I have been provided with information about the service including the limitations to privacy and confidentiality and I have agreed that in circumstances where the counsellor is concerned about my welfare and is unable to contact me permission is provided for the counselling to contact my nominated emergency person as stated in the New Client Intake Form.

I have read and understood the information in this Consent Form and have discussed any outstanding questions with ALY’S PLACE Research-Based Counselling for Couples and Individuals.