General Information

Please read all the information on this page and, if you consent, click the "I consent" button and electronically sign your name in the space provided.

Psychological or Allied Mental Health Service

As part of providing a psychological or allied mental health service to you your clinician 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 as part of providing psychological services to you. 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

As part of providing a psychological or allied mental health service to you your clinician 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 as part of providing psychological services to you. 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 assessment and/or therapeutic intervention, 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 psychologist or clinician to provide a relevant and informed psychological or allied service to you. A more detailed description is provided in PSI Connect’s Data Privacy Policy, which can be viewed when making a booking or obtained by contacting PSI Connect via email: engage@psiconnect.org. The Data Privacy Policy contains information about how to access and seek correction of your personal information, and how to lodge a complaint about the management of your personal information.

Confidentiality & Disclosure Of Personal Information

The ethical principles that guide the practice of psychology protect the privacy of all communications between client and clinician. All client information is subject to privacy laws. Thus, information about your interaction with your clinician can only be released to others with your written consent.

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

1. It is reviewed by a clinical supervisor for professional development and quality assurance; or

2. It is subpoenaed by a court, or disclosure is otherwise required or authorised by law; or

3. Failure to disclose the information would in the reasonable belief of the psychologist place you or another person at serious risk to life, health or safety; or

4. Your consent 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, e.g., a parent, employer, health provider or third-party funder; or

c. Disclose the information in another way; or

d. Disclose 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.

Your personal information will not be disclosed to third parties, 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.

In the event that unauthorised access, disclosure or loss of a client’s personal information occurs, your clinician will activate the data breach plan and use all reasonable endeavours to minimise any risk of consequential serious harm.

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 Data Privacy Policy, your clinician may not be able to provide the psychological or allied service to you. You may request to be anonymous or to use a pseudonym, unless it is impracticable for your clinician to deal with you or if your clinician 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. The clinician may discuss different possible forms of access with you.

Email Privacy Disclosure

Clients are reminded that they are to use email at their own discretion. The clinician is unable to guarantee the privacy or confidentiality of the medium. If you are concerned with the use of email, please request your clinician not use the format. The clinician will follow the lead of the client and disclaims any liability for privacy breaches of the medium if it is utilised by the client as a means for communication.

Fees And Consultation Length

Typical consultation length is around 50 minutes, with the cost of a consultation variant depending on the type of referral. Payment for sessions is required at the time of the service, unless alternate arrangements have been made with your clinician. Please talk with your clinician if you are experiencing financial hardship - concession rates can be discussed. If payment is covered by a third-party payer, then PSI Connect will invoice the third party directly.

Cancellation Policy And Non-Attendance Fees

A late cancellation is considered cancellation of a scheduled appointment any time the day prior to the scheduled appointment. A Non-attendance fee in the amount of the full consultation fee is charged if less than one full business days’ notice is given (i.e., cancellation at any time the day prior to your appointment). Reminder messages are sent prior to your scheduled appointment. Cancellation Fees are applied at the individual clinicians’ discretion.

Personal Details

Emergency Contact

Mental Health and Relevant Medical History

Telehealth

During your treatment with PSI Connect, you will likely be provided service via Telehealth. The information below is a consent form to enable PSI Connect to provide services to you in this way.

Where appropriate the services you receive 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. Our practice will be responsible for the cost of the call to you and/or the cost associated with the platform used to conduct telehealth services.

To access telehealth consultations, you will need access to:  

1. A quiet, private space;

2. An appropriate device, such as a smartphone, laptop, iPad, or computer with a camera, microphone, and speakers; and

3. A reliable 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 Microsoft Office which is compliant with the Australian standards for online security and encryption. A closed-loop AI service might be used to summarise case notes and transcripts. You can read more about Microsoft's Security Privacy and Compliance measures here.

A telehealth consultation may be subject to limitations such as an unstable network connection which may affect the quality of the session provided. In addition, there may be some services for which telehealth is not appropriate or effective. Your practitioner will consider and discuss with you the appropriateness of ongoing telehealth sessions.

Informed Consent

At this clinic, regardless of clinician type, we employ the APS Charter for Clients of Psychologists as a practice guideline. The APS Charter for Clients of Psychologists explains your rights as a client of a psychologist. Your clinician can direct you to this charter upon request.

Please note: If, after reading this form you are at all unclear about any of the information provided, discuss with your psychologist or clinician prior to your appointment or prior to signing the document.

I consent for my clinician to collect, store and utilise this personal information for the purposes of providing services to me in accordance with the relevant privacy legislation and any other legal requirements that may apply. I consent for my clinician to communicate with my referring GP about my care, this may occur in written form (reports/letters) or spoken (phone liaison). I have read and understood this consent form. I agree to the above conditions for the psychological service provided.