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.


 

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 Psychologist). 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 and other such issues 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. Zoom video conferencing will be employed. Zoom only transmits encrypted information, never has access to personal information and does not

persistently store information that is transmitted. The limits of this can be read further at www.zoom.us

 

Use of therapy session materials

Clinicians will not make recordings of our sessions or use material from sessions for purposes other than delivering a service to you. Clinicians will seek your written consent they wish to use material for other purposes (such as consultation with colleagues). We ask you to respect our privacy by agreeing not to make recordings of 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 consent to do so.

 

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

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 and anonymous. 

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 standard clinic consultation (50 minutes) is $128.40 for up to 20 sessions.

 

The cost for sessions after 20 or for certain after-hours clinic consultations (50 minutes) with a Clinical Psychologist is $203.40, General Psychologist $167.45 or other Medicare registered health professional $152.10. All are payable at the end of the session by cash or credit card. Medicare rebate will be processed and returned to you within 1-2 days of your sessions leaving a gap fee of $75 in each instance where a Mental Health Care Plan is in place. A valid credit card should be provided prior to the first appointment which is held as part of your client record. No payment will be taken unless you choose to pay for a session by credit card, or fail to provide adequate notice for canceling or postponing an appointment (see cancellation policy below). A $30 holding fee for your first appointment will be taken on booking and refunded once the first appointment has been attended. If the first appointment is not attended without 24 hours notice, this fee is non-refundable. 

 

  

Cancellation Policy

If, for some 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). If this notice is not provided and your appointment cannot be filled, you will be charged 50% of the private session fee ($62.25). This will be charged automatically to the credit card provided.

 

To cancel appointments:

• 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 Monday – Saturday.


 

Please do not directly email your clinician as they may not action this in a timely manner.

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