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Client Registration Form

ABOUT YOU

CONTACT PREFERENCES & EMERGENCY CONTACTS

Funding and Referral

Relationships & Family

HEALTH AND PREVIOUS SUPPORT

CONSENT, PRIVACY AND PRACTICE INFORMATION

CONFIDENTIALITY AND SHARING INFORMATION

Confidentiality and sharing information

We keep your personal and health information confidential. It may be disclosed only when:

• you have given consent for information to be shared (for example, with your GP, another health professional, lawyer, employer or family member);

• sharing is reasonably expected and directly related to the purpose for which the information was collected;

• disclosure is required or authorised by law, including a valid subpoena or court order; or

• I reasonably believe disclosure is necessary to lessen or prevent a serious threat to the life, health or safety of you or another person, and it is unreasonable or impracticable to obtain consent.

Telehealth

Sessions may be provided by telephone or videoconference where appropriate. You are responsible for your own device, internet connection and a quiet, private space. Achieve Counselling Service pays the cost of calls made to you and the telehealth platform. Internet-based services can have privacy and technical limitations, including connection problems. If telehealth is not clinically suitable or effective, we will discuss other options.

Session recording and clinical notes

NovoNote may be used to record sessions so I can focus on the conversation rather than continuous note-taking. We use the audio recording for clinical note preparation and delete it within 48 hours. Please indicate your preference at the consent section of this document.

Medicare bulk billing

Where a psychology service is bulk billed, I agree to assign the Medicare benefit for that service to Victoria Walters of Achieve Counselling Service as full payment. I will obtain and record any required assignment-of-benefit consent in accordance with current Medicare requirements.

Screening, reports and court matters

• I may use brief psychological screening questionnaires where clinically appropriate. I do not provide comprehensive or major psychological testing; I may recommend specialist assessment when required.

• I do not provide forensic psychological services or prepare court, child-custody or family-law reports.

• If records or information are legally required by subpoena, court order or other law, I will respond only as required.

• Letters or reports requested for anyone other than your referring doctor are charged at $110 per hour (GST inclusive), payable in advance.

Cancellations and missed appointments

If you cancel or do not attend an appointment without giving at least 12 hours' notice, a $50 fee will apply and must be paid before your next appointment. We normally send a reminder message the morning before your appointment as a courtesy.

Session recording and clinical notes

Your consent to receive therapy

By signing below, you confirm that you have read and understood this information and agree to the terms that apply to your care.


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