Consent For Service

Consent For Service Form

Consent for a psychological telehealth service 
As part of providing a psychological service to you/ your child, Back On Track Psychology needs to collect and record personal information from you that is relevant to you/ your child’s current situation, such as your (child’s) 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.

Purpose of collecting and holding information
Your personal information is gathered as part of your (child’s) assessment and treatment. It is kept securely and, in the interests of your privacy, used only by your psychologist, the authorised personnel of the practice (as necessary), and the data will also be stored at a third-party provider located outside of Australia. At the time of your booking, your personal information will also be shared with a third-party provider that will be storing your data outside of Australia. Your personal information is retained in order to document events happening during sessions, and enables the psychologist 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 Back On Track Psychology. 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, Back On Track 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 Back On Track Psychology to deal with you or if Back On Track 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.

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 (for example, the exceptions as set out in the National Privacy Principle Six). Back On Track Psychology may discuss with you appropriate forms of access.

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
      • provide a written report to another professional or agency. e.g., a GP or a lawyer; or
      • discuss the material with another person, e.g. a parent, employer or health provider; or
      • 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.
    6. under national law, registered psychologists are required to seek supervision from a colleague approximately once a month to discuss their practice. It is possible that some aspects of your treatment will be discussed anonymously with another psychologist.

My Health Record (MHR)
You agree that your treating psychologist viewing your MHR as required throughout the time you attend psychological treatment.

Concerns about management of personal information
If a client has a concern about the management of their personal information, they should inform Back On Track Psychology. Upon request, a copy of the National Privacy Principles can be provided which describe your rights and how information should be handled. Back On Track Psychology can also provide you with a copy of the practice’s Privacy Policy which contains information about how to lodge a complaint about our management of your personal information.

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. Back On Track Psychology 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.

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 platform/technology which is compliant with the Australian standards for online security and encryption.

Benefits of telehealth
The benefits of telehealth can include:

  • Decreased travel time
  • Decreased child and elder-care cost associated to face-to-face appointment
  • Continued therapeutic support during a pandemic (i.e. COVID-19)
  • Sessions outside of business hours
  • Overcome the barrier of anxiety symptoms that prevent individuals to leave home or accessing face-to-face services
  • Better access for individuals who live in remote location
  • Ease of rescheduling appointments
  • Increased client’s satisfaction

Limitations of telehealth
A telehealth consultation may be subject to limitations such as an unstable network connection which may affect the quality of the psychology session. If technical difficulties interfere with the session to the point it cannot be continue, a phone consultation will be offered as an alternative. The appointment might require to be rescheduled on some occasions due to technical difficulties. Telehealth may not feel the same as a face to face session. Although my psychologist chooses video conferencing software, which has end-to-end encryption and high security standards, there is still a small risk of hacking or other tapping into the video connection.

In addition, there may be some services for which telehealth is not appropriate or effective. Your psychologist will consider and discuss with you the appropriateness of ongoing telehealth sessions.

Telehealth Precautions
Back On Track Psychology also took the necessary precautions to ensure confidentiality including:

  • Ensuring the privacy of the telehealth session is upheld in the same way an in-person session would be, by choosing a private location and using headphones.
  • The experience of the telehealth session is also upheld as closely as the in-person session would be, including appropriate dressing, and you would initiate the appointment call at your booking time.
  • All appointment bookings are done online. Both text messaging and email are discouraged as a form of communication due to increase likelihood of miscommunication. Limited amount of sessions can be provided by text messaging, but this has to be discussed with the treating psychologist.
  • It is important to note that email is not a secure form communication as it can be intercepted (or impersonated) by third party, human errors (email sent to the wrong address).
  • It is important to be on time. If you need to change or cancel the appointment, you must notify the psychologist in advance by phone or email. Cancellation policy applies.
  • Email, phone and text messaging are used largely for administrative purpose and not for clinical use. Response time, including enquiry may take up to one to three business days.
  • Not allowing any voice or video recording of the session unless otherwise discussed.
  • It is important for both parties to use a secure internet connection rather than public/free Wi-Fi.

Fees
The cost of a 50-minute consultation is $215, which is payable by credit/debit card at the time of booking. Appointment that is not booked online will incur a 2.5% credit card processing fee. Your psychologist will discuss with you your eligibility for Medicare or other compensable funding (i.e., private insurance, OSHC). Back On Track Psychology do not have bulk billing service. The invoice and booking confirmation will be email to your nominated email account. Please discuss with your psychologist if you do not wish so.

Non-attendance, Late-attendance and Cancellation Policy
If you need to cancel or postpone your appointment, please give the psychologist at least 24 hours’ notice, otherwise you may be charged the cost for the session due to non-attendance or cancellation. A refund (minus the transaction fee, which is 2.5% of the booking fee) will be provided for cancellation with at least 24 hours’ notice. 

If you show up 15 minutes late for your session without any notice, the appointment will be cancelled, and you may be charged the cost for the session.

APS Charter for Clients of Psychologists
There is a Charter that explains your rights as a client of a psychologist. A copy can be made available to you at your request.

Consent to receive psychological services by telehealth

  • I have been provided with information about the service including the limitations to privacy and confidentiality.
  • I have been informed of and understand the payment / Medicare processes for my telehealth session, and consent to comply with these.
  • I understand the risk of communication via email, and agree to receive confirmation booking and invoice at your nominated email account.
  • I understand that I can ask questions about the telehealth session at any time.
  • I have agreed that in circumstances where the psychologist is concerned about my welfare and is unable to contact me permission is provided for the psychologist to contact the emergency contact person as provided by the client or as discussed during the session.
  • If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telehealth sessions.

Please note: If, after reading this form you are at all unclear about any of the information provided, please contact the psychologist prior to your appointment. The psychologist will discuss the information in this consent form with the client and received verbal consent to proceed with telehealth services.

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