Consent Form

As part of providing psychological therapy 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. If you do not agree to the privacy policy, the consultation cannot be undertaken.

All personal information gathered during the provision of the psychological service will remain confidential and secure except when:

  1. It is subpoenaed by a court; or

  2. If there is a risk to the life, health or safety of an individual or the public that can be averted only by disclosing information (this no longer needs to be imminent)

  3. To assist with locating missing person; or

  4. Your prior approval has been obtained to

  5. provide a written report to another professional or agency, e.g. a GP or a lawyer; or

  6. discuss material with another person, e.g. a parent or employer.

5. This form and your file is only handled by myself (Susan Crisford).

6. Under the Commonwealth Privacy Act you have the option to interact    anonymously or by using a pseudonym.

7. Please note that if you are referred under a Mental Health Care Plan I am required to write a letter back to your referring Doctor that includes among other things your diagnosis. I am also required by Medicare to provide your Doctor with regular written updates on your progress in therapy as per medicare or other requirements. If you are concerned about the content of these letters, please discuss this with me.

8. I acknowledge that the session will not be recorded unless both parties consent, that no one else will be present to hear/see the call unless I advise my Psychologist, and that if there is any breakdown in the call that my Psychologist will call me back on my mobile phone.