Consent Form Personal Particulars

Date*

I am completing this form as:

a client of Strategic Psychologya guardian accompanying a child / young person

Full name*

First NameLast Name

Date of birth*

Address*

Street Address

Street Address Line 2

CityState

Postal Code

Phone number*

E-mail*

First name

Surname

Date of birth*

Age*

Client address

Same as above guardianDifferent to above guardian

Address*

Street Address

Street Address Line 2

CityState

Postal Code

Phone number

E-mail

Consent to receive psychological therapy
Psychological therapy can help you gain insight into your thoughts, feelings, and behaviours and develop strategies to manage them more effectively. Therapy can also improve relationships, reduce stress and anxiety, and increase well-being. Although therapy can be beneficial, it may also involve discussing painful or difficult experiences, which can be emotionally challenging. Additionally, therapy may not be effective for everyone, and there is no guarantee that therapy will produce the desired results. By signing below, you acknowledge that you have read and understand this information and agree to participate in psychological therapy.

Psychological service
As part of providing a psychological service (i.e., counselling, assessment, report writing), Strategic Psychology needs to collect and record personal information such as your name, contact information, medical history, personal circumstances and other relevant information. This collection of personal information is a necessary part of the assessment and treatment process.

Psychological assessments
Psychological assessments may be offered as part of your psychological service. These assessments involve the use of standardised tests, interviews, and observations to evaluate your cognitive, emotional, behavioural, or psychological functioning. The purpose of these assessments is to gain a deeper understanding of your strengths, challenges, and needs, and to inform recommendations or treatment planning. The results of psychological assessments will be provided to you in a report. Additional discussion of the findings with your psychologist may occur as appropriate. Like other services, participation in psychological assessments is voluntary, and the information collected will be handled in accordance with the privacy and confidentiality guidelines outlined in this consent form.

Purpose of collecting and holding information
The personal information recorded as part of your mental health assessment and treatment is kept securely and, in the interests of your privacy, used only by your psychologist and the authorised personnel of Strategic Psychology (as necessary). Your personal information is retained in order to assist the continuity of care and enable your psychologist to provide a relevant and informed psychological service to you. From time to time, Strategic Psychology may also use third parties to support our operational needs (such as bookkeeping services) and relevant information may be passed on in these cases.

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, Strategic Psychology may not be in a position to provide the psychological service to you.

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. Your psychologist may discuss with you different possible forms of access.

If you are attending sessions as part of couples counselling, seeking access to your personal information will apply to only the sessions you have attended individually or as a couple and will not include the other parties individual sessions. In the event you access your personal information which includes shared sessions, you agree to not misuse that information nor to broadcast it.

Consent for AI-assisted technology use

As part of our ongoing efforts to provide the highest quality care, we may use AI-assisted technology to support clinicians with note-taking during your sessions. This process may involve the recording of your appointment for the following purposes:

To assist your clinician in accurately documenting your session.
To ensure the completeness and quality of the notes taken during your session.

Please note the following important details regarding this process:

Session recordings are strictly confidential and will only be accessible to the clinician providing your care.
Recordings are temporary and will be permanently deleted after the clinician has completed and verified the notes for your session. No recording will be retained beyond that point.
The recordings are not used for any other purposes beyond note-taking and will not be shared with any third parties.
Your participation in this process is entirely voluntary, and you may request that your session not be recorded. This will in no way affect the care you receive.
Data security measures are in place to ensure that any recordings are stored in a secure and encrypted manner during the short period they are retained.
You have the right to revoke your consent at any time and request that no further recordings be made.

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

1. it is subpoenaed by a court, or disclosure is otherwise required or authorised by law; or
2. failure to disclose the information would in the reasonable belief of the psychologist or authorised personnel of Strategic Psychology, place you or another person at serious risk to life, health or safety; or
3. your prior approval 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, eg. 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.

4. the psychologist is legally required to report a medical or psychological condition that may impair your ability to safely operate a heavy vehicle, or if you are in the process of applying for a heavy vehicle licence, as per ACT mandatory reporting guidelines.

Your personal information is not disclosed to overseas recipients, 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, Strategic Psychology will activate its data breach plan and use all reasonable endeavours to minimise any risk of consequential serious harm.

Consent for communication with your general practitioner (GP)
If you are attending Strategic Psychology under a Mental Health Treatment Plan as part of the Better Access to Mental Health Care Initiative, your psychologist is required to communicate with your referring GP. This may include sharing relevant information about your treatment, such as progress updates, to ensure coordinated care. By signing this consent form, you acknowledge and agree to this communication between your psychologist and your GP as mandated by the initiative.

Fees and cancellation policy
Full fees are payable at time of booking. You may cancel or reschedule without charge by emailing support@strategicpsychology.com.au prior to 48 business hours of your consultation time - We do not accept rescheduling or cancellations by phone. Cancellations or rescheduling within 48 business hours of your consultation will be charged the full fee unless a medical certificate is provided.

Authority for disclosure of personal information to a third party

I consent to my psychologist or authorised personnel of Strategic Psychology to provide information relating to me to the following listed persons/organisations.

Important - read in full: to ensure you receive the best possible support, please provide details of all relevant professionals involved in your care. This includes your GP as well as any rehabilitation providers, Psychiatrist, lawyers, case managers, school psychologist or other key contacts. If you are a young person, consider adding your parents. Listing these contacts helps us coordinate your care effectively. If no one else is involved, simply write 'Nil'.*

Example: Dr Peter Jones - Woden Surgery - 12 Pine Street, Woden ACT 2607 - (02) 6262 6262

First Name

Surname

Date of birth*

Full name of guardian accompanying the child / young person (if applicable)*

First NameLast Name

Date of birth*

The above Charter explains your rights as a client of Strategic Psychology.*

I have read and understood this Consent Form. I agree to the above conditions for the psychological service/s provided by Strategic Psychology.

Signature*

For the purposes of signing this consent form, this electronic signature shall be deemed the same as an authentic signature*

I agree

Date*

Date for file

Date

Consent Form

Guardian Details:

Client Details:

Consent Information

Client Authority