THERAPY CONSENT FORM
As part of providing counselling services to you, ALY'S PLACE 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. This collection of personal information will be a necessary part of the therapeutic assessment and treatment that is conducted.
Purpose of collecting and holding information
Your personal information that is gathered as part of your assessment and treatment, is kept securely and, in the interests of your privacy, used only by your counsellor and the authorised personnel of the practice (as necessary). Your personal information is retained for documenting what happens during sessions, and enables the counsellor to provide a relevant and informed counselling service to you.
Consequence of not providing personal information
Access to client information
At any stage, you are entitled to access your personal information kept on file, subject to exceptions in the Health Records Act 2001. The counsellor may discuss with you different possible forms of access.
Disclosure of personal information
All personal information gathered by the counsellor during the provision of the counselling service will remain confidential except when:
1. it is subpoenaed by a court; or
2. failure to disclose the information would in the reasonable belief of ALY'S PLACE 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.
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.
NOTE: In couples counselling, discussion of matters concerning the partners attending counselling may be required for the best therapeutic outcome. Therefore, any information you disclose with the counsellor in individual sessions during the course of the couples counselling is not considered to be breach of confidentiality and may be shared with the other partner if relevant and appropriate. If one of the partners in couples counselling explicitly wishes some information to remain private and confidential, your counsellor will ensure that this information is kept confidential.
The cost of a consultation, which is usually around 60 or 90 minutes, is payable at the end of the session by cash, direct deposit, EFTPOS or credit card (Master card and Visa only). For first time clients we may request an upfront payment via a bank transfer to secure your appointment, If for some reason you would need to cancel or postpone that first appointment, the Cancellation Policy as described below will apply.
If payment is covered by a third party, ALY'S PLACE will make suitable arrangements with this party and inform you of them. For NDIS clients, the fee for a 60 minute session is $156.16 inclusive of GST.
If, for some reason you need to cancel or postpone your appointment, please give the counsellor at least 48 hours/ 2 days’ notice, otherwise you will be charged a $50 cancellation fee. In the event that you do not provide any notice, you will be charged the full amount of the consultation fee.
I have read and understood this Consent Form. I agree to the above conditions for the counselling services provided by the counsellor at ALY’S PLACE.