THERAPY CONSENT FORM
Counselling Services
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
If you do not wish for your personal information to be collected in a way anticipated by this letter or the Privacy Policy, ALY'S PLACE may not be able to provide counselling services to you. You may request to be anonymous or to use a pseudonym, unless it is impracticable for ALY'S PLACE to work with you, or if is required, or authorised by law to deal with identified individuals.
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.
Fees
The cost of a consultation, which is usually around 60 or 90 minutes, is payable on the day of the session by credit card (Master Card and Visa only), cash, or direct deposit. Automated credit card payment (Card on File) is preferred.
For payments that are outstanding 14 days or longer after the booked appointment date, a late payment fee of $50 for each week (7 days) after the initial 14-day period applies.
For telehealth appointments, we require Credit Card on File or a bank transfer with payment confirmation at least 24h prior to your appointment.
For our first-time clients, we may request an upfront payment of $50 via a credit card or a bank transfer to secure your appointment. The initial booking deposit is non-refundable and if for some reason you would need to cancel or postpone that first appointment, the deposit will be used to partially cover the missed session fee.
As of 1January 2024, the costs for consultations with our counsellors are as follows: $260 for 90 min and $150 for 60 min. Higher fees apply for consultations with the lead counsellor ($330 for 90 min and $220 for 60 min). A $50 surcharge applies for sessions outside of the regular working hours 11 am-7 pm and on Saturdays.
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.
Cancellation Policy
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 or cancel on the day of your appointment, 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.