• Image-15

  • Intake and Consent Form

  • We ask you to complete our Intake and Consent Form to collect the personal details necessary for Strategic Psychology to provide services, and to outline the policies, consent requirements, fees, and responsibilities involved in working together. This ensures we can deliver care tailored to your needs while informing you of your rights, our confidentiality practices, and the treatment process. By completing and signing this form, you confirm that the information provided is accurate and that you have read, understood, and agreed to the terms and consents included.

    • Client Information 

    • Client Information

      The “Client” refers to the individual for whom psychological services are requested and who will attend the appointment.
    •  / /
    • Parental Responsibility 

    • Parental Responsibility

    • Browse Files
      Drag and drop files here
      Choose a file
      Cancelof
    • Parent/Guardian 1 Information  

    • Parent/Guardian 1 Information

    •  / /
    • Send to Parent/Guardian 2 

    • Parent/Guardian 2 Details (Consent Required)

      Because parental responsibility is shared, a copy of this completed form will be emailed to Parent/Guardian 2 after submission. They will be asked to review the information and confirm their consent for the psychological services to proceed. Please provide the following details for Parent/Guardian 2:
    • Couples - Send this form to parter 

    • Couples Counselling

      Important: Couples counselling is not eligible for Medicare rebates under a Mental Health Treatment Plan (MHTP).
    • GP Referral 

    • Referral Details

    • Browse Files
      Drag and drop files here
      Choose a file
      Cancelof
    • Medicare 

    • Medicare Details of the Client

      The “Client” refers to the individual for whom psychological services are requested and who will attend the appointment.
    • Emergency Contact 

    • Emergency Contact

    • Consent, fees and cancellation policy 

    • Informed Consent

    • 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:

      1. Session recordings are strictly confidential and will only be accessible to the clinician providing your care.
      2. 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.
      3. The recordings are not used for any other purposes beyond note-taking and will not be shared with any third parties.
      4. 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.
      5. 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.
      6. 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
        1. provide a written report to another professional or agency. e.g., a GP or a lawyer; or
        2. discuss the material with another person, eg. a parent, employer, health provider or third party funder; or
        3. disclose the information in another way; or
        4. 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 the time of booking. You may cancel or reschedule without charge by emailing support@strategicpsychology.com.au at least 48 business hours before your scheduled consultation. Please note that we do not accept cancellations or rescheduling requests by phone. Changes made within 48 business hours of your appointment will incur the full fee unless a valid medical certificate is provided.

    • Disclosure to GP 

    • Authority for disclosure of personal information to GP

    • I consent to my psychologist or authorised personnel of Strategic Psychology to provide information relating to me to my GP:

      Name of GP: Dr {gpName}

      Practice name: {gpPracticeName}

    • Disclosure to third party 

    • Authority for disclosure of personal information to third party

      You may wish to include details of any people or organisations involved in your care, such as a rehabilitation provider, psychiatrist, lawyer, case manager, school psychologist, or others supporting you. If you are a young person, you may also wish to include your parents. If you choose to provide these details, please include their name, role, organisation, address, and contact details.
    • Agreement (Client) 

    • Agreement (Client)

    • Clear
    •  / /

    • IMPORTANT: After you click the "Submit" button, please stay on the page to complete the self-report questionnaire.

    • Declaration of Sole Parental Responsibility (Parent/Guardian 1) 

    • Declaration of Sole Parental Responsibility (Parent/Guardian 1)

    • You have indicated that you currently hold sole parental responsibility without a formal court order, and that no other parent or legal guardian is actively involved in the child’s care, upbringing, or decision-making.

      By signing below, you confirm the following:

      I, {parent1Name} (Date of Birth: {parent1DOB}), declare that I am the primary caregiver and hold sole responsibility for the care, upbringing, and decision-making of my child, {clientFirstName} {clientSurname} (Date of Birth: {clientDOB}).

      To the best of my knowledge:

      • There are no court orders, parenting plans, or legal agreements granting parental responsibility or decision-making authority to any other person.
      • There are no legal restrictions preventing me from consenting to a psychological services for my child.

      I confirm that this declaration is true and accurate. I understand that Strategic Psychology is relying on this information to proceed with psychological services without the consent of another parent or guardian. I agree to notify Strategic Psychology immediately if any legal circumstances change or if another party asserts parental rights.

    • Clear
    •  / /
    • Agreement (Parent/Guardian 1) 

    • Agreement (Parent/Guardian 1)

    • Clear
    •  / /

    • IMPORTANT: After you click the "Submit" button, please stay on the page to complete the self-report questionnaire.

    • Agreement (Parent/Guardian 2) 

    • Agreement (Parent/Guardian 2)

    •  / /
    • Clear
    •  / /

    • IMPORTANT: After you click the "Submit" button, please disregard the self-report questionnaire that you will be taken to as {parent1Name} has already completed this.

    • Always hidden 
    •  - -
    • Should be Empty: