Consent Form Adult

As part of providing a psychological service to you, your psychologist will need to collect and record personal information that is relevant to your current situation. Collection of personal information is a necessary part of psychological assessment and therapy.

Purpose of Collecting and Retaining Information

Information is gathered as part of the assessment, diagnosis and treatment of a client’s condition, and is only seen by the psychologist. The information is retained in order to document what happens during sessions, and enables the psychologist to provide a relevant and informed psychological service. The psychology services provided by your clinic are bound by the legal requirements of the National Privacy Principles from the Privacy Amendment (Private Sector) Act 2000. All communications between you and your psychologist become part of your clinical records, which are stored in your client file. Client filesare held in asecure filling cabinet and electronically that is accessible only by your treating psychologist.

Confidentiality

With the exception of certain specific exceptions as described below, you have the absolute right to confidentiality of your information.You are assured that all personal information gathered by the psychologist during the provision of the psychological service will remain confidential and secure. However, it is important to know that there are exceptions in which all psychologists are mandated (by law) to break confidentiality.

This can occur when:

The information you have given to your psychologist is subpoenaed (officially requested) in a court of law
Failure to disclose the information would place you or another personat serious risk of harm
Your prior approval has been obtained to:
a. Provide a written report to another professional or agency e.g. GP or lawyer
b. Discuss the material with another person e.g. A parentor employer

Exchange of Client Information

There may be times where, as part of the assessment and therapy process, it may be helpful for your psychologist to liaise with other people or agencies that are relevant to your therapy goals (e.g. Your GP, specialist, parent, WorkCover, etc). Please note that if you intend to claim rebates from Medicare or another organisation (such as WorkCover or TAC) then your psychologist must provide summary reports to external agencies regarding your treatment progress. Under the Medicare scheme these reports will normally be sent to your GP or psychiatrist.

Appointments

If therapy is begun, sessions are typically scheduled once per week for 50minutes at a time you and your therapist agree on, although some sessions may be longer or more frequent. Couples, family or group therapy sessions may be routinely scheduled for 90 minutes or longer. Missed sessions and late arrivals are problematic for both clients and therapists.Therefore, we ask clients to make a commitment to attend regularly. If you find regular attendance is a problem for you, we ask that you consider whether this is the most appropriate time or type of clinic for you. At times, you may do better to terminate therapy and start at a later date when you can make a regular commitment.

Fees

Fees are payable at the time of consultation.

Cancellation Policy

As you can understand it is nearly impossible for a psychologist to book in a new client at very short notice. A late cancelled appointment is a loss to three people:

The client who is delaying their therapy progress
Another client who is on the waiting list to see the psychologist urgently
The psychologist who spent the morning preparing for the session
Our clinic policy is as follows:
A minimum of 24 hours’ notice is required to cancel your appointment and you will not incur a fee (unless your appointment is on a Monday where you will need to contact the clinic by 12pm Saturday to cancel your appointment without penalty)
Cancelling an appointment within 24 hours incurs a fee equivalent to your consultation fee which will be charged and required to be paid when you call to cancel your appointment. This cannot be claimed back through Medicare.
Cancelling an appointment due to illness under 24 hours from your appointment will incur a fee of 50% of your consultation fee.
If you are unable to attend your appointment and you do not let the clinic know, you will incur the full fee of your consultation.
These fees, in the interests of fairness, apply to all clients and cannot be altered by the practice manager or reception staff.
If you have cancelled or missed a session it is your responsibility to contact the clinic to reschedule
If you miss two or more sessions in a row, your therapist will try to contact you by phone. If we are unable to contact you, we will send you a letter and we will assume that you are well and no longer require our services.
If you wish to end therapy, we at The OCD Clinic Brisbane request that you discuss this with your therapist rather than simply failing to show up.
Therapists are required to inform the Principal Psychologist of recurrent late cancellations or missed appointments.

Outcome Measures and Feedback

Following your assessment you and your clinician will develop a treatment plan. At our clinic we pride ourselves on meeting and exceeding your treatment needs. In order to do so, we will regularly seek feedback both verbally and electronically. This may mean that at times after your session you may be required to stay an extra 10 minutes to answer several carefully selected questions to assess that we are meeting your needs. These tests also measure outcomes so we can ensure that treatment is moving in the right direction and if not, problem solve why it is not. This information is stored securely in paper and electronic files and only your psychologist has access to this information.

By ticking the boxes below this indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. If you have any questions or are unclear about any policy, please feel free to discuss these with your therapist prior to signing this document.

Feeling afraid as if something awful might happen? *

I consent to treatment

I understand that I (and/or my child’s) information will be recorded as part of my treatment

I have read and understood the limits to confidentiality

I have read and understood the exchange of information

I understand that Anxiety House does not provide emergency services and that I must form a plan with my therapist for how to obtain emergency care when needed

I have read and agree to the cancellation policy

I have read and agree to complete outcome measures as part of my treatment

I have read and agree that my outcome data may be used by the clinic in a research project providing all my responses are anonymous

I consent to receive the newsletter

Name *

Date

Upload Signature *

Maximum file size: 8.39MB

PROJECT TITLE: TREATMENT EFFICACY RESEARCH PROJECT

Anxiety House and The OCD Clinic Brisbane (here after referred to as the Clinic/s)value and encourage the routine use of questionnaires for the purposes of:

Assessing the progress of clients in therapy
Research projects

By signing this document, I acknowledge that:

My participation is voluntary;
I am free to withdraw from the project at any time without explanation and withdrawing will not affect my treatment at the Clinic/s;
The project is for the purpose of research and not for profit;
Any information about me which is gathered in the course of and as the result of my participating in this project will be
(i) de-identified, collected and retained for the purpose of this project and
(ii) accessed and analysed by theresearcher(s) for the purpose of conducting this project;
My anonymity will be preserved and I will not be identified in publications or otherwise without my written consent; and
Any questions I have asked have been answered to my satisfaction.

Consent *

I consent to participate in the project named above (please tick box).

Name *

Surname, First Name, MI

Date *

Upload Signature *

Maximum file size: 8.39MB

Personal Details

Please provide the following information for our records. Leave blank any question you would rather not answer. Information you provide here is held to the same standards of confidentiality as our therapy.

Full Name *

Surname, First Name, MI

Date of Birth *

Age

Home Address *

Home Address

City

State/Province

Zip/Postal

Number of Children *

Gender *

Male

Female

Marital Status *

Never married

Partnered

Married

Separated

Divorced

Widowed

Medicare *

IRN *

Valid to *

Home Number

May we leave a message? *

Yes

Mobile Number *

May we leave a message? *

Yes

Email *

May we email you? *

Yes

Are you currently receiving psychiatric services, professional counselling or psychotherapy elsewhere? *

Yes

If yes, what is your therapist's name?

Have you had previous psychotherapy? *

Yes

If yes, what is your previous therapist's name?

Are you currently taking any prescribed medication? *

Yes

If yes, please list *

If no, have you been previously prescribed psychiatric medication? *

Yes

How did you hear about us? *

Health and Social Information

How would you describe your physical health at the moment? *

Poor

Unsatisfactory

Satisfactory

Good

Very Good

Please list any persistent physical symptoms or health concerns *

(e.g. Chronic pain, headaches, hypertension, diabetes, etc.)

Are you having any troubles with your sleep habits? *

Yes

If yes, please check all that apply

Sleeping too little

Sleeping too much

Poor sleep quality

Disturbing dreams

OthersOthers

How many times per week do you exercise? *

How long is each exercise session? *

Are you having difficulty with appetite or eating habits? *

Yes

Do you regularly drink alcohol? *

Yes

In a typical month, how often do you have 4 or more drinks in a 24 hour period?

How often do you engage in recreational drug use? *

Daily

Weekly

Monthly

Rarely

Never

Have you had any suicidal thoughts recently? *

Frequently

Sometimes

Rarely

Never

Have you had any suicidal thoughts in the past? *

Frequently

Sometimes

Rarely

Never

Are you currently in a romantic relationship? *

Yes

In the last year, has your child / adolescent experienced any significant life changes or stressors? *

Have you ever experienced any of the following? *

Extreme depressed mood

Wild mood swings

Rapid speech

Extreme anxiety

Panic attacks

Phobias

Sleep disturbances

Hallucinations

Unexplained losses of time

Unexplained memory loses

Alcohol/substance abuse

Frequent body complaints

Eating disorder

Body image problems

Repetitive thoughts (i.e. Obsessions)

Repetitive behaviours (e.g.Frequent handwashing, checking)

Homicidal thoughts

Suicide attempt

OCCUPATIONAL INFORMATION

Are you currently employed? *

Yes

If yes, who is your current employer?

What is your current position?

Please list any work related stressors, if any

Has anyone in your family (immediate or relatives) experienced difficulties with the following? *

Depression

Bipolar Disorder

Anxiety Disorders

Panic Attacks

Schizophrenia Alcohol/Substance Abuse

Eating Disorders

Learning Disabilities

Trauma History

Suicide Attempts

OTHER INFORMATION

What do you consider to be your strengths? *

What do you like most about yourself? *

What are effective coping strategies that you’ve learned? *

What are your goals for coming to therapy? *

If you are human, leave this field blank.

Consent Form Adult

Purpose of Collecting and Retaining Information

Confidentiality

Exchange of Client Information

Appointments

Fees

Cancellation Policy

Outcome Measures and Feedback

PROJECT TITLE: TREATMENT EFFICACY RESEARCH PROJECT

Personal Details

Health and Social Information

OCCUPATIONAL INFORMATION

OTHER INFORMATION

Sample Title

Sample Title

Clinical Supervision Contact Form

Supervision Contact Form

Clinical Psychologist Registrar Program Application

Administration Application

Psychologist Application

Consent Form Adult

Purpose of Collecting and Retaining Information arrowup6

Confidentiality arrowup6

Exchange of Client Information arrowup6

Appointments arrowup6

Fees arrowup6

Cancellation Policy arrowup6

Outcome Measures and Feedback arrowup6

PROJECT TITLE: TREATMENT EFFICACY RESEARCH PROJECT arrowup6

Personal Details arrowup6

Health and Social Information arrowup6

OCCUPATIONAL INFORMATION arrowup6

OTHER INFORMATION arrowup6

Sample Title

Sample Title

Purpose of Collecting and Retaining Information

Confidentiality

Exchange of Client Information

Appointments

Fees

Cancellation Policy

Outcome Measures and Feedback

PROJECT TITLE: TREATMENT EFFICACY RESEARCH PROJECT

Personal Details

Health and Social Information

OCCUPATIONAL INFORMATION

OTHER INFORMATION