BORONIA

157 Scoresby Road,
Boronia VIC 3155

Ph: 9839 3300

Fax: 9839 3380

CLIENT DETAILS:

DATE:

Please select clinic location:

FTG Clinic Boronia Clinic

Are you (or is the person) Aboriginal and/or Torres Strait
Islander Origin
Yes No

Jobseeker Payment Recipient:

Yes No

If relevant- Parent/Guardian

EMERGENCY CONTACT

REFERRAL DETAILS (for Office use- Psychologist to complete)

Type of referral:

Medicare (GP referral) Private Worksafe TAC


*DUE TO DEMAND FOR THIS SERVICE, UNFORTUNATELY IF YOU DO NOT CONTACT US BY 12 NOON THE DAY PRIOR TO CONFIRM YOUR SCHEDULED
APPOINTMENT A CANCELLATION FEEWILL BE CHARGED AND WE CANNOT GUARANTEE A FURTHER APPOINTMENT UNTIL THE FEE IS PAID.


CLIENT CONSENT FORM / CONTRACT / INFORMATION SHEET

Psychological Service

As part of providing a psychological service to you, I will need to collect and record personal information from you that is relevant to your current situation. This information will be a necessary part of the psychological assessment and treatment that is conducted. You do not have to give all of your personal information however it may impact on your treatment or mean that this psychological service is not appropriate if you don’t.

Purpose of collecting and holding information

The information is gathered as part of the assessment, diagnosis and treatment process and is seen only by the psychologist unless otherwise consented. The information is retained in order to document the content and process of sessionsand enables the psychologist to provide a relevant and informed psychological service.

Access to Client Information

At any stage, you as a client are entitled to access the information about you kept on file, unless the relevant legislation provides otherwise (Commonwealth Privacy Act 1988). The psychologist may discuss with you appropriate forms of access.For further information regarding the collection, handling, storage and access to your personal information, please request a copy of the ‘Fernhills Clinic Privacy Policy’ from our reception staff or your psychologist.
Code of Conduct/Ethics

The psychologist will act in an ethical and professional manner at all times and in accordance with the code of ethics laid out by the Association & Registration Board this psychologist is a member of.
1. The psychologist is qualified in the area of psychology.
2. The psychologist reserves the right to refer clients to other professional services when the psychologist considers this course of action to be in the best interests of the client.
3. The psychologist aspires to promoting what is good for the client by enhancing well-being.
4. The psychologist is committed to exercising care in avoiding activities that have a high risk of hurting clients, even inadvertently.
5. The psychologist aims to foster independent decision making in clients who the psychologist believes have freedom of thought and freedom to choose their own direction.
6. The psychologist is committed to providing a fair and equal service to all clients.
7. The psychologist aims to create a trusting and therapeutic climate in which people can search for their own solutions.

Limitations to Confidentiality

The psychologist reserves the right to inform outside agencies or other relevant parties on issues relating to the client’s confidentiality as law dictates. These instances are:-

1. When clients pose a danger to others or themselves.
2. The client is under the age of 16 and is a victim of incest, rape, child abuse etc.
3. Information is made an issue in a court action.
4. The client requests that information be released.
5. To assist in the location of a missing person.
6. The client discloses identifying information about a major crime.

Fee and Service Schedule

1. Please be aware that Fernhills Clinic is not an emergency service and cannot provide this service.
2. Sessions will run for 50 minutes each. Unfortunately, if you arrive late for an appointment,your psychologist is not able to run past the original allocated
duration
3. Payment is by Eftpos, Visa or Mastercard. Cash is not kept on the premises to provide change.
4. The cost of a 50 minute session varies depending on the psychologist that you are seeing and will be discussed with you at the time of booking your appointment. All reports written by Psychologists will be charged at the Psychologists recommended fee.
5. Medicare,Private Health Fund,Work-cover and TAC rebates are available.

Client's Rights & Responsibilities

1. To attend sessions punctually.
2. To notify clinic by 12 noon the day prior to your scheduled appointment, if unable to attend. You must notify the clinic by 12 noon Saturday if you are unable to attend an appointment scheduled for the Monday following.
3. Payment for sessions is on the same day as service. Late payment will result in an additional late payment fee.
4. To ensure that you have turned off all electronic equipment including mobile phones.
5. The client has the right to withdraw their consent to treatment at any time.
6. To keep clinic informed of any changes to contact details and/or consent to contact others.

If the client is unhappy at any stage with the quality of service they have received, we encourage them to notify the clinic via reception or the Practice Manager, to register a complaint. Should you consider either that your confidentiality has been breached or a request for access/correction has been unfairly denied, you may lodge a complaint with the Office of the Australian Information Commissioner (OAIC) or AHPRA. A copy of our privacy policy is available to view upon request at our reception

Cancellation of Appointments

Due to demand for this service, unfortunately if you fail to arrive for a scheduled appointment or do not cancel by 12 noon the day prior to your appointment, we cannot guarantee a further appointment, and this will also incur a cancellation fee.

give informed consent for my psychologist

Please read through the above information carefully and sign where indicated to confirm that you have read, accept and understand the conditions above and that any uncertainties have been queried with and clarified by the practitioner.


Phone and Video Counselling TELEHEALTH

Generally speaking, the same code of ethics and principles apply for phone/video counselling as when we meet clients for face-to-face consults. The below are some guidelines to help ensure an effective and successful phone/video counselling session.

1. Your privacy during phone / video counselling is of utmost importance and all reasonable steps will always be taken to secure your personal information.
2. Depending on network coverage, your Psychologist/MHSW will use their mobile phone (with no caller ID) for making phone calls to your nominated phone number.
3. For video consultations, your Psychologist/MHSW will use their chosen platform which fulfils the recommended standards (eg, end-to-end encryption) to protect the privacy and security of video conferencing, however Fernhills Clinic cannot guarantee TOTAL protection against security beaches within this platform. The privacy of any communication via the internet or mobile device is potentially vulnerable and limited by the security of the technology itself (eg., hacking). These risks are small but do exist.
4. During video counselling sessions please adhere to the following - wear appropriate / modest clothing (just as you would when attending the clinic), please position your camera at desktop height & above, please sit in a comfortable chair, and do not have any personal items in view (that you would not want others to see)
5. The Psychologist/MHSW and the client (you) agree to never record phone / video counselling sessions. If for some reason you wish to record our sessions, please seek your psychologist/mhsw’s consent. You can expect your therapist to undertake these sessions in a private setting, free from distractions and other people. It is strongly recommended that you also find a private location where you can speak freely and comfortably.
6. find a private location where you can speak freely and comfortably.
7. Where possible, please use a headset / headphones to improve sound quality and to improve your privacy
8. Please minimise distractions during your session time – do not play games or be responding to emails / text messages during these sessions
9. Please test your audio quality before beginning the session
10. Please check that you have enough data / phone coverage to undertake these sessions. Your therapist will take all reasonable measures to establish a reliable connection however we cannot take responsibility for any disruptions to your phone / video call (eg due to poor internet speeds). If a reliable connection cannot be established, then your therapist will contact you via email to arrange another session time.
11. The Psychologist/MHSW will not be responsible for covering the cost of the call / data. At any time during the consultation, you have the choice to stop the phone / video call.
12. If your presenting concerns and level of associated risk are deemed as not appropriate to be managed remotely, then a referral to a provider / service within the community will be discussed.

These above considerations are in conjunction with the usual client contract agreement that forms part of the informed consent process.


FERNHILLS CLINIC CANCELLATION POLICY

Should you be unable to attend an appointment, please notify reception as soon as possible. Appointments not cancelled by 12 noon the day prior incur a cancellation fee. If you need to cancel a Monday appointment, please ensure you contact the clinic by no later than 12 noon the Saturday before, to avoid the cancellation fee.

Common Misconceptions:

Q. Do I have to pay for my sessions?

A. If you are bulk-billed, Medicare pays a rebate to the treating psychologist when you attend. We are unable to bill Medicare for a rebate for any session where a client has failed to attend.

Q. Do Psychologists receive a salary?

A. Psychologists in private practice do not receive a salary. We are paid per session that a client attends. If a client does not attend a session, the psychologist does not get paid. However, the associated clinic costs do not vary and must be covered.

Q. My psychologist has rescheduled my appointments before when they’ve been away, what’s the difference?

A. Unfortunately unforeseen circumstances can arise. We try to minimise these occurrences as much as possible. When appointments are rescheduled due to a psychologist being away sick, the psychologist does not receive any income. A psychologist’s sick or annual leave is always without pay.

Q. I’ve decided to go somewhere else, is that okay?

A. We respect everyone’s right to make the decision that best suits them. However, most services function in a similar way to that outlined above.