Client Information Form

Psychological Services
As part of providing a counselling service to you, your counsellor will need to collect and record personal information from you that is relevant to your current situation. This information will be a necessary part of the assessment and treatment that is conducted.
The personal information that is gathered is kept securely and, in the interests of your privacy, used only by your psychologist and the authorised personnel of the practice (as necessary).
Access
You may access the material recorded in your file upon request, subject to the exceptions in National Privacy Principle 6.
Confidentiality
All personal information gathered by the counsellor during provision of the counselling service, will remain confidential and secure except when:
1. It is subpoenaed by a court;
2. Failure to disclose the information would place you or another person at serious risk;
3. Your prior approval has been obtained to:
a) provide a written report to another professional or agency. e.g. GP or lawyer;
b) discuss the material with another person, e.g. a parent or employer.
4. Disclosure is otherwise required or authorised by law;
5. Your counsellor is not available, the CEO or another counsellor within Wavecare may access details as required.
6. You would reasonably expect your personal information to be disclosed 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.
To ensure we are providing a high quality service, clinical audits will be done each year.
Fees and Cancellation Policy
The cost of a consultation (usually around 50 minutes) is per Wavecare’s schedule of fees and is payable at the end of the session.
If you need to cancel or postpone an appointment, please give 24 hours notice, otherwise the full fee will be billed for late cancellations/missed appointments.
If you require a letter or a report, two or more consultations will be required and a fee will be charged commensurate with the type of document required.

I, (print name)………………………………………………………., have read and understood the above Consent Form. I agree to these conditions for the service provided by Wavecare.