Consent Form
1. Purpose of Service and Personal Information
As part of providing psychological counselling, your mental health practitioner will collect and record personal information that is relevant to your circumstances, assessment, and treatment. This information supports the delivery of safe, effective, and evidence-based care. If your practitioner is a registered psychologist, they are regulated by the Australian Health Practitioner Regulation Agency (APHRA) and bound by the Psychology Code of Conduct. Other qualified mental health professionals may be governed by their respective professional bodies and code of ethics.
All information collected is stored securely and is only accessed by your psychologist and authorised personnel at Wavecare Counselling Inc (Wavecare) when required for administrative or clinical purposes.
2. Confidentiality and Limits
Your privacy is protected by professional and legal standards, including the Privacy Act 1988 (Cth), Health Records Act 2001 (Vic), and relevant professional codes of conduct (including the Psychology Code of Conduct for registered psychologists). Information you provide will remain confidential except in the following circumstances where disclosure is required or permitted by law:
a. A court subpoenas your file or information.
b. There is a serious or imminent risk to your safety or the safety of another person.
c. Mandatory reporting obligations apply under Victorian and Commonwealth legislation, including the Children, Youth and Families Act 2005, Disability Act 2006, and relevant professional registration requirements where applicable (e.g., concerns of child abuse or neglect, abuse of people with disabilities or when required to protect public safety).
d. You provide prior written consent to:
o share information with another professional or service (e.g., GP, school, or legal representative)
o communicate with a nominated family member or support person.
5. If your practitioner is unavailable, the CEO or another qualified Wavecare clinician may access your information if required to support your care.
e. When you would reasonably expect information to be shared with other health or support providers directly involved in your care.
f. Routine quality assurance checks, including internal clinical audits, may occur to ensure high-quality service delivery and compliance with relevant professional standards and regulatory requirements. Any information used for this purpose will be managed confidentially.
In addition to the above, information may be disclosed for peer supervision and case consultation without identifying details (as described in Section 3 below).
3. Professional Supervision & Case Presentation
To maintain high ethical and professional standards as required by professional registration standards and best practice guidelines, Wavecare mental health practitioners participate in regular peer supervision and case consultation.
Your case may be discussed in these settings without identifying details (de-identified), to ensure:
• High-quality service delivery
• Clinical safety
• Ongoing professional development
If you have concerns about this process, please speak to your practitioner.
4. Access to Your Records
You may request access to information in your file at any time. Access may be subject to limited exceptions permitted under privacy legislation. Your practitioner will discuss any considerations with you before access is provided.
5. Practitioner Qualifications and Registration
Wavecare employs qualified mental health professionals who may include:
Registered Psychologists - regulated by APHRA under the Psychology Code of Conduct.
Other qualified mental health professionals (e.g., counsellors, social workers, provisional psychologists and placement students) - governed by their respective professional associations and codes of ethics.
Your practitioner's specific qualifications and registration details are available upon request and will be discussed during your initial consultation.
6. Complaints Process
If you have concerns about the professional conduct or performance of your mental health practitioner, you may:
• Discuss the matter directly with your practitioner or Wavecare management.
• Lodge a complaint with APHRA (for registered psychologists) by calling 1300 419 495 or visiting www.ahpra.gov.au, or contact the relevant professional association for other mental health professionals; or
• Contact the Health Complaints Commissioner (Victoria) by calling 1300 582 113 or visiting www.hcc.vic.gov.au.
7. Fees & Cancellation
• Sessions are approximately 50 minutes and charged according to Wavecare’s current fee schedule and payment is required on the day of service.
• A minimum of 48 hours’ notice is required for cancellations.
• Late cancellations or missed appointments incur the full session fee, and Medicare rebates cannot be claimed for these fees.
• If you require letters or reports, additional fees will apply based on the nature of the request.
Consent Declaration
I have read and understood the information in this consent form.
I agree to psychological services being provided by Wavecare in accordance with the terms outlined above and understand that my practitioner is bound by their relevant professional code of conduct and regulatory requirements.
I understand I can withdraw consent at any time, though this may affect the continuity of my care. I also understand that certain legal obligations may require disclosure of information even after withdrawal of consent.
Client name (print): ____________________________________Signature: ________________________
Date: ____ / ____ / ______
