I, the undersigned patient or legal guardian, hereby acknowledge that I have read and understood the disclosure, terms, and conditions provided below, and I consent to the medical care and procedures outlined by Dr. Robert Brennan.

 

Disclosure, Terms & Conditions:

 

Consent to the Provision of Services for Clients of WillowVale Clinic Psychology Services

As a consequence of the provision of psychological services, WillowVale Clinic, will require the collection of personal information relevant to your situation. All personal information (such as your name, contact details, next of kin, and relevant medical information) is kept securely to protect your privacy and can only be accessed by your psychologist and/or authorised personnel at WillowVale Clinic when necessary. Where care for you and your family/significant others may extend beyond a single practitioner, when deemed necessary or relevant, case discussion may be required between treating practitioners at WillowVale Clinic to ensure the best outcomes for everyone.

Records of Session Content

All personal disclosures, session content, and assessment data are kept confidential between the client and therapist and securely stored in accordance with the APS Ethical guidelines; however, exceptions exist to confidentiality and are listed below. This collection of information is needed to document what happens during sessions, to monitor progress toward intervention goals, and to assist in the provision of relevant evidence-based intervention and or assessment.

Consent to Standard Medical Intervention:
Dr. Brennan fully supports patients who have been diagnosed with cancer to pursue standard-of-care medical treatments for their cancer diagnosis, including surgery, chemotherapy, immunotherapy, targeted therapy, hormone therapy, or radiation. We believe that standard-of-care treatments are vital for a positive outcome. We encourage patients to work in conjunction with their oncologists. Dr. Brennan does not promise or guarantee a cure or specific outcomes for any condition, especially cancer.

General Consent:
WillowVale Clinic offers certain accessory functional pathology tests, treatments, and products that may not be covered by Medicare or PBS (Government Funding) or Private Medical Insurance. These tests and treatments are supported by empirical knowledge and are used with utmost care by Integrative Medical Practitioners.

 

Communication via Email/Text:
By signing this form, you consent to communicate with WillowVale Clinic via email, online forms, and/or text message. You acknowledge that email, online forms, and text communication may not be completely secure and that any decision to use such communication will be documented in your clinical records. You understand that confidentiality will be respected, and emails or texts will not be forwarded without the consent of all parties involved. 

The health practitioners at WillowVale Clinic will not be able to call or email a patient outside of a consult and they spend almost all their time at the clinic in consultation with clients face-to-face or via telehealth or telephone. 

Any medical questions are best handled in the context of a consultation. We recommend first checking your consultation summaries or information sheets provided by the WillowVale Clinic practitioners, then making a face-to-face, phone, or telehealth consultation if the answer cannot be found.

Your emails are received and actioned by our wonderful Reception team; who are not clinical staff and cannot provide medical recommendations

 

Fees and Supplements:
You acknowledge that there will be private fees applicable for consultations, supplements, or treatments at WillowVale Clinic, which may not be rebatable by Medicare or insurance. Consultation fees will be clearly specified to you by your doctor prior to treatment. You understand the importance of following the prescribed supplement regimen as directed by your doctor and agree to attend scheduled reviews.

I understand and acknowledge that practitioners at WillowVale Clinic may benefit, either directly or indirectly, from tests or supplements recommended at the practice.

I am attending WillowVale Clinic voluntarily and consent to receive treatment(s) based on my own judgment and the information provided to me. I understand that any information obtained during my time at the clinic may be used for research and publication purposes in a de-identified manner.

I am aware that private fees will be applicable for my consultation, supplements, or treatments at WillowVale Clinic, and these fees are not eligible for reimbursement by Medicare or insurance. The specific consultation fees will be clearly communicated to me by my doctor prior to treatment.

 

Confidentiality
All information gathered in the provision of medical services will remain confidential and secure except where:
1) There is a serious and imminent risk to yourself or someone else
2) There is reasonable suspicion a child is at risk or is being mistreated
3) Your records are subpoenaed by a court
4) Your prior approval has been obtained to provide a written report to a requested professional agency (e.g.specialist, university, lawyer, etc) or to discuss information with another person (e.g., family member, employer)

 

Telehealth Consent & Information
In 2020, in response to the COVID-19 Pandemic, telehealth services were introduced and have been extended until December 2026.

Our practice predominantly utilises Halaxy Telehealth or Zoom to deliver our telehealth services. Privacy remains as per our usual process, refer to the Confidentiality section in this document, and we will treat your information with respect and in confidence. We will not record telehealth sessions nor share material from telehealth sessions without your consent. Telehealth services utilise interactive cloud-based systems that involve sharing of audio, video, or other data communication online (outside of our practice). Our practitioners make a commitment that we will undertake these calls in a private setting where others cannot hear your information. We recommend that you also find a private setting where you feel comfortable too. It is important that steps are made by you to protect your information. If you are not able to find a private location where you feel comfortable let your psychologist know when they call and they will respect your request. Your privacy is important, and we will respect your decision.

 

Safety & Confidentiality
If your medical team is concerned about your safety or the safety of others, the usual limitations (as outlined in the Consent section in this document) apply. If your practitioner fears for your safety during or upon the termination of a session, they may contact the emergency contact person (nominated by you) to ask them to check on you. Your practitioner will make every effort to ensure you are feeling safe and supported, however, due to the nature of online telehealth services there will be a greater need for you to utilise your self-regulation strategies. If you are concerned about your level of ability to self-regulate, please discuss with your practitioner and they can work with you to develop these skills to ensure you feel safe and grounded in between sessions.

 

Consent for Telehealth Services
I accept the method of Telehealth services, and I have read, understand and agree to the above information. I agree to pay the negotiated fee as per one of the options provided. I also agree to my doctor or psychologist lodging the rebate with Medicare on my behalf, should my bank details be registered.

I have read and understood this Consent Form. I agree to the conditions outlined above for the provision of medical services at WillowVale Clinic. I consent for WillowVale to take notes during the consultation and keep them in a confidential file. I have read and understood the Consent for Telehealth Information. I agree to the conditions outlined above and consent to Telehealth Services from WillowVale Clinic should I require Telehealth Services. I have read, understood, and agree to the information and conditions outlined above by WillowVale Clinic.

 

Acknowledgment:
By signing below, you acknowledge that you have read and understood the disclosure, terms, and conditions outlined above. You understand the nature of our health practitioners' practice and have consented to the terms and conditions.