Consent and Confidentiality

1
Name
First Name
Last Name
2
Please read and agree to our Confidentiality PolicyClients should be assured that all information provided in the process of consultation is strictly confidential. Only the assigned counsellor/provider, and the designated case supervisor(s) may have access to the information, except under special circumstances. Again, except under these special circumstances, no information may be released to others without the written consent of the individual client. These special circumstances include the following: 1. Where a court orders the release of client information for legal purposes. 2. Where the counsellor/provider is obligated under his/her professional registration to disclose information in order to prevent potential harm to you or to another person. 3. Where a person discloses sexual offences against a child (person under 16 or person under 18 with an intellectual, psychiatric or neurological disability) this must be reported to the police unless there is a reasonable excuse for not doing so. You may be asked by your counsellor/provider to sign a form providing your consent for the release of records and information. This will happen when, for example, you are under a doctor’s care for a medical issue that is relevant to the reasons for which you are seeking services at this clinic or if you have a significant psychiatric history. This allows your counsellor/ provider at the clinic to work as part of a ‘team’ with others in providing you the best care possible. It may also allow your counsellor/ provider to have access to important information that may be necessary in order to provide you with appropriate care. You have the right to refuse this consent. However, in certain situations, your refusal may mean that you will not be able to proceed with services. You may also be asked to sign a form providing your consent for your counsellor/provider to talk with one of your family members about your situation. Again, you have the right to refuse this consent and the communication will never happen without your consent. Australian Counselling Association and Psychotherapy and Counselling Federation Australia are the two accrediting bodies for Counsellors. Please refer to the ACA and PACFA code of conduct to understand what you can expect from your provider here at this clinic ACA scope of practice: https://www.theaca.net.au/documents/ACA_Scope_combined.pdf PACFA scope of practice: https://pacfa.org.au/portal/Portal/Prac-Res/Resources/PACFA-Scope-of-Practice.aspx Do you agree to this Confidentiality Policy?
Yes
No
3
Emergency and After-Hours Coverage'Dr Patrick Pheasant - Counselling, Coaching & Consulting' is not a crisis centre. If you are concerned about your personal safety or the safety of others please call 000 for emergency services or go to your closest hospital’s emergency department. If you are an existing patient of Dr Patrick Pheasant and are unable to contact him the following options are available until he is able to respond to you: · Call 000 for an ambulance if you or someone else is suicidal or in danger · Call 000 for the police if the situation is violent · Lifeline - 13 11 14 · NSW Domestic Violence Line - 1800 656 463 · Mental Health Line - 1800 011 511 · Salvation Army 24hr Care Line - 1300 363 622 · Kids HelpLine (5-25yrs) - 1800 551 800 You are encouraged to share any experienced after-hours emergencies as soon as possible with your counsellor/provider. Do you agree to this Emergency and After-Hours Coverage?
Yes
No
4
Cancellation PolicyWe understand that unforeseen circumstances sometimes arise. If you need to cancel your counselling appointment, please do so with at least 48 hours' notice. Cancellations made more than 48 hours in advance will be rescheduled without penalty. Cancellations made within 48 hours of your appointment will incur a 50% fee of the session cost. Missed appointments without notification will be charged the full session cost. Rescheduling: We will do our best to accommodate your desired rescheduled appointment time. This policy helps us ensure that cancelled appointments can be offered to other clients in need. We appreciate your understanding and cooperation. To cancel your appointment, please text at 0434881060 or email us at contact@patrickpheasant.com.au. Do you agree to this Cancellation Policy?
Yes
No
5
Email
example@example.com
6
Mobile Number
04XX XXX XXX
Should be Empty: