CONSENT FOR TREATMENT FORM

CONSENT FOR TREATMENT FORM

Lionhearted Counselling and Expressive Therapies
Please do not proceed to complete this form unless your referral to Lionhearted Counselling and Expressive Therapies has been discussed and confirmed.*

My referral has been confirmed

Lionhearted Counselling

Rashidah Fido

***

You have the right to be informed regarding the terms under which treatment will be provided. Policies related to charges, appointments, emergencies, and coverage for when I am unavailable will be discussed at the initial intake session.

In the case where a minor is the client, then the parent(s) or legal guardian has/have the right to refuse or stop treatment for the minor. I also have the right to refuse or terminate treatment, in which case you will be provided with alternatives. It is my hope that if you have concerns regarding your treatment or wish to discontinue treatment that you will discussed this with me.

As part of providing counselling services to the young person, Lionhearted Counselling and Expressive Therapies will need to collect and record personal information that is relevant to their current situation. This information is a necessary part of the clinical assessment and treatment.

Information is gathered as part of the assessment and treatment of the young person and is seen only by the treating clinician. The information is retained in order to document what happens during sessions, and enables us to provide relevant, informed and evidence-based services. The collection, storage, transfer and use of personal information will be undertaken in a secure manner such that it fully protects all personal and sensitive information. On the cessation of connection Lionhearted Counselling and Expressive Therapies, the personal information will be held securely for as long as it is prudent and in line with Australian Association of Social Workers protocol.

Therapy is most effective when a trusting relationship exists between therapist and the client. Privacy is especially important in securing and maintaining that trust. One goal of treatment is to promote stronger and better relationships between children and their parents/guardians. However, it is often necessary for children to develop a “zone of privacy” whereby they feel free to discuss personal matters with greater freedom with their therapist. This is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy. I will incorporate parent work at times, but this will also be dependent on the young person’s developmental stage. Agreements on the level of disclosure to the parent/guardian will be developed on a case-by-case basis.

The limits of confidentiality will be discussed with the young person so that they are aware that the therapist has a legal obligation to keep them safe. Exceptions to confidentiality are if there is a risk to a young person or someone else’s safety and where/if contact with Child Protection, police or acute mental health services need to be made. There is a legal requirement to disclose information when the court issues a subpoena for our records.

Because we live in a relatively small community, it is not unlikely that I will see clients in public. If this occurs, it is my policy not to initiate contact. Instead, I leave it up to my clients to decide whether they want to talk to me as an extra protection of their confidentiality.
I understand the above information:*

Yes
One of the therapeutic techniques that I employ is sandtray and sandplay therapy. If the young person participates in this type of therapy with me, I want you to understand that a photographic record of the sandtray/sandplay therapy will be made and kept on the young person’s file, following all applicable legal and ethical rules of confidentiality. I engage in sandplay supervision and from time to time photographs will be referred to in this process to assist with my practice.

By signing this form I understand that Rashidah may engage in sandtray/sandplay therapeutic techniques and I will advise her if my child is allergic or has an aversion to sand.
I understand the above information:*

Yes
A cancellation charge of $50 is applicable if notice has not been given within four hours of the appointment commencing.
I understand the above information:*

Yes
Due to confidentiality and privacy laws, Lionhearted Counselling and Expressive Therapies cannot release any information provided during assessment and treatment unless you give your written consent. You have a right to request to revoke consent at any point in time. This may limit certain types of services from being provided (e.g., Medicare Rebated Services).

Agreed relevant other services include:
- GP and hospital
- Mental Health Services
- Department of Health and Human Services (CPU, Medicare, Centrelink)
- Counselling Services
- The Police
- School and Wellbeing
I understand the above information:*

Yes
Specific services not agreed to:
I consent for Lionhearted Counselling to liaise with the agreed relevant other services in order to provide the best service:*

Yes
By signing below, I affirm that I have read and understood and agree with the statements within this document. Further, I authorize Rashidah Fido from Lionhearted Counselling and Expressive Therapiesto provide counselling to type client name here. I understand that I am also assuming ultimate financial responsibility for the cost of the treatment and I am aware cancellation fees cannot be paid by Medicare. I am also aware of cancellation charges and that if I arrive late I will still be charged the usual fee for this session due to this time being set aside for your child.
Signature of young person:

Clear
Date signed above:

MonthDayYear
Signature of parent/legal guardian:

Clear
Date signed above:

MonthDayYear
Should be Empty: