Informed Consent Form

Psychological services

As part of the psychological services provided to you, embodipsyc will collect and record personal information that is relevant to your situation, such as your name, contact details, medical history and other relevant information as part of the provision of psychological services.

Privacy and confidentiality

Your personal information is gathered as part of your assessment and treatment. All of this is kept securely and, in the interests of privacy, used only by your psychologist and other authorised staff (as necessary). Your privacy and the information you provide is protected at all times. Your psychologist adheres to the ethics and code of conduct requirements of the Psychology Board of Australia and its regulating body, the Australian Health Practitioner Regulation Agency (AHPRA). Your personal information is retained in order to document what happens during your sessions, and enables your psychologist to provide a relevant and informed psychological service to you. You are entitled to access your personal information kept on file at any time by making a request of your psychologist.

Your information will be kept strictly confidential except when:

  1. It is subpoenaed by a court

  2. You give permission to release your information to a third party

  3. Disclosure is otherwise required by law

  4. You disclose a serious risk to life, health or safety to yourself or others

  5. Your psychologist is consulting with other psychological supervisors and/or peers to further improve the support and treatment provided to you (whom in turn will maintain strict confidentiality of your information).

Cancellation policy

Please give at least 24 hours notice if you are unable to attend your appointment, otherwise you may be charged a late cancellation / non-attendance fee. This must be paid in full prior to your next session. Late cancellations for situations beyond your control (e.g. illness, car failure, family emergency) are acceptable and will not incur a fee.

Consent

By signing this informed consent form, you acknowledge that you have read and understood all the terms and conditions of service and agree to the provision of psychological services by Embodipsyc.

I have read and understood these terms and conditions: