Consent Form
Psychological service
As part of providing a psychological service to you, Mums Matter Psychology 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 psychological assessment and treatment that is conducted.
Some services may be provided by Registered Provisional Psychologists under the supervision of the Director, Frances Bilbao (Clinical Psychologist).
Purpose of collecting and holding information
Your personal information is gathered as part of your assessment and treatment, is kept securely and, in the interests of your privacy, used only by your clinician and the authorised personnel of the practice (as necessary). Your personal information is retained in order to document what happens
during sessions, and enables the clinician to provide a relevant and informed psychological service to you. A more detailed description is provided in the practice’s “Privacy policy for management of personal information”, which can be obtained by contacting Frances Bilbao (Principle Clinician). 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.
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, Mums Matter Psychology may not be in a position to provide the psychological service to you. You may request to be anonymous or to use a pseudonym, unless it is impracticable for Mums Matter Psychology to deal with you or if Mums Matter Psychology 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 Mums Matter Psychology 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 clinician may discuss with you different possible forms of access.
Disclosure of personal information
All personal information gathered by the clinician 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 the Clinician, 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.
Electronic and SMS Communication
For administrative communication regarding appointment times receipts you will be communicated to via your email address. You will receive appointment reminder SMS to your phone. If you do not wish to receive email or SMS communication for this purpose, please inform your clinician.
Telehealth
Requirement to provide contact details and location
When working together by videoconference, clinicians need to be able to contact support people in your locality should any issues arise. You will be asked to provide the names and contact details of at least 1 person known to you before we commence the treatment. Because you may be in varied locations for each videoconference, clinicians will require you to provide your location at the commencement of each session.
Privacy in online communications
The privacy of any form of communication via the internet or a mobile device is potentially vulnerable and limited by the security of the technology. Google Meet video conferencing will be employed. Google Meet only transmits encrypted information, and does not persistently store information that is
transmitted unless you authorise it to. The limits of this can be read further at https://policies.google.com/privacy?hl=en-US
Transcription of Sessions
Some clinicians choose to use NovoNote solely to transcribe the notes obtained during the session. and as set out below:
● The recording may include your personal information, including sensitive information such as your health information.
● The recording may be shared with third parties to generate summaries of the session and for any related or necessary purpose
● Your personal information will be treated with strict confidentiality, and the data will be securely stored and encrypted.
● Your authorised clinician will have access to the transcripts and you may request a copy from your clinician at any time.
● The transcripts will be retained by your clinician as required by law and NovoNote will temporarily retain a copy for internal auditing purposes. The transcripts and any recording will be permanently deleted by Novonote thereafter.
Please refer to the NovoNote privacy policy here https://novopsych.com/novonote-privacy-policy-security/
Social Media
Our clinicians do not accept friend or contact requests from current or former clients on any social networking site (Facebook, Linkedln, etc). This can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship.
Quality Assurance, Feedback and Complaints
From time to time you will receive an SMS requesting you complete a short survey to provide feedback on your session with your clinician. This is for the purpose of service improvement and is voluntary. You will be contacted for further follow up by the Director if you let us know you are unhappy with your experience so we can attempt to rectify the situation.
At anytime, if you would like to submit feedback or a complaint, please contact Frances Bilbao, the Director at frances@mumsmatterpsychology.com as the first point of call for resolution.
You will also be asked how things are going via email after your third session and sent an anonymous feedback survey at the end of your care with us.
Medicare Bulk-Billing
If you have a valid GP Mental Health Care Plan the cost of your standard clinic session will be automatically bulk billed to Medicare for up to 20 sessions (for the lifetime with the service). No payment will be required by you. As part of this arrangement, you agree to the Assignment of your Medicare Benefits to your clinician.
Other Fees
The cost of a non-Medicare private clinic consultation varies and can be found on the “Fees” section of the Mums Matter Psychology website. A valid credit card should be provided prior to the first appointment which is held as part of your client record. This credit card will be used to pay for any privately funded sessions, and cancellation fees if applicable (see paragraph below).
Cancellation Policy
If, for any reason you need to cancel or postpone your appointment, please provide at least 24 business hours notice (for Monday appointments this means the Friday before your appointment). When frequent cancellations happen, delays in your treatment plan can occur. This in turn slows the recovery process which is vital to the overall well being of all of our clients. If this notice is not provided and your appointment cannot be filled, we will charge a cancellation fee, as per the fees at the time provided on the Mums Matter Psychology website.
To ensure you are able to cancel or reschedule in a timely manner, please do this via:
• Confirmation Email – Click on “Reschedule/Cancel” button in your confirmation email to reschedule or cancel online at anytime.
• Phone – please leave a voicemail at 9079 6930. Voicemails are actioned between 8:30am and 5:30pm 7 days per week
Please do not directly email your clinician as they may not action this in a timely manner.