Consent Form
Consent for a psychological service (including telehealth)
As part of providing a psychological service to you, Peace Infusion and/or Mindful Synergi needs to collect and record personal information from you that is relevant to your situation, such as your name, contact information, medical history and other relevant information as part of providing psychological services to you.
This collection of personal information will be a necessary part of the psychological assessment and treatment that is conducted.
A detailed description of how your personal information is managed, how you can access your personal information, and how to lodge any concerns or complaints about this service or how your personal information is managed must be provided to you by your health professional upon request.
Disclosure of personal information (Limits to liability)
We are committed to your privacy. Personal information gathered as part of this service and all discussions and records remain confidential unless disclosure is required under the following circumstances:
Legal obligations, such as a subpoena
Failure to disclose the information would be in the reasonable belief of Sheree Simpson, place you/your child or another person at serious risk to life, health or safety
Criminal activity
Your prior approval has been obtained to:
provide a written report to another professional or agency, e.g. a GP or lawyer; or
discuss the material with another person, e.g. a parent, employer or health provider; or
disclose the information in another way
Consent Regarding Privacy
By proceeding with booking an appointment, you indicate your understanding of the following privacy requirements:
You understand that in accordance with Medicare requirements, in order to receive the Medicare Rebate, my psychologist must communicate with the referring practitioner (GP, Psychiatrist).
This information will be general in nature and largely relate to the content of treatment and progress. Nevertheless, I understand that I retain the right to specify if something specifically is to remain confidential.
Provision of a telehealth service
Where appropriate the service will be provided by videoconferencing or phone.
You are responsible for the costs associated with setting up the technology needed so you can access telehealth services.
Peace Infusion and/or Mindful Synergi will be responsible for the cost of the call to you and the cost associated with the platform used to conduct telehealth services.
To access telehealth consultations, you will need access to a quiet, private space, and the appropriate device, i.e. smartphone, laptop, iPad, computer, with a camera, microphone and speakers, and a reliable broadband internet connection.
You agree to avoid multitasking (e.g., driving, messaging) during sessions.
The privacy of any form of communication via the internet is potentially vulnerable and limited by the security of the technology used. To support the security of your personal information this practice uses Zoom, which is compliant with the Australian standards for online security and encryption.
A telehealth consultation may be subject to limitations such as an unstable network connection which may affect the quality of the psychology session. In addition, there may be some services for which telehealth is not appropriate or effective. Your psychologist will consider and discuss with you the appropriateness of ongoing telehealth sessions.
Medicare Sessions
Clients who are referred under a Mental Health Care Plan are currently eligible for up to 10 (ten) sessions per calendar year. Please note that you are responsible for keeping track of the number of sessions you have used. We will provide you with a verbal reminder when you are due for a review with your referring doctor. Medicare rebates do not apply to sessions with provisional psychologists.
Fees
Initial Consultation $235
Subsequent Consultation $220
To secure your booking, the Initial Consultation fee will be processed at the time of making the booking. Subsequent Consultations will be processed after the appointment through the online booking system, Halaxy, or via in-clinic payment using Square.
If you require a report or letter for a specific purpose (e.g. court), the standard rate will apply for report writing time. Please see a forensic psychologist if you require a court report.
Private Health Insurance
Some private health insurance companies provide rebates for psychological services. Please check with your provider to see if you are eligible. We will provide you with an invoice which may allow you to make a claim. It is your responsibility to ensure that you have the right to claim from your private health insurance provider.
Cancellation Policy
You understand and agree that when less than 48 hours’ notice is given for rescheduled or cancelled sessions, the full session fee will apply and be charged to your credit card on file.
You understand that cancellations must be made via text, phone call or email between 8am and 5pm, more than 48 hours before the scheduled appointment to avoid a cancellation fee.
You understand and agree that in the event of a payment default, you will be responsible for the payment of any costs incurred in the collection process.
Communication Outside of Sessions
Sheree Simpson does not generally have the capacity to communicate with clients outside of scheduled sessions. Communication between sessions should be limited to administrative matters only, such as rescheduling appointments or confirming details. This communication is typically handled by the Mindful Synergi admin team via phone or email.
If you require support between sessions, please discuss this with Sheree to develop an appropriate care plan.
After-Hours and Emergency Support
Peace Infusion and Mindful Synergi are not a crisis service, and we are unable to provide after-hours support. If you are in crisis or experiencing a mental health emergency, please contact one of the following:
Emergency Services (000)
NSW Mental Health Line – 1800 011 511
Lifeline – 13 11 14
Your local hospital emergency department
Please raise any concerns about safety or support needs with Sheree during session time so that a care plan can be established.