Welcome to the Health Psychology Clinic. There is a lot of information we are legally required to share with you in order to provide you with a safe and compliant psychological service.

Please take a moment to read the following information. If you have questions and would like to discuss anything before signing this agreement please raise this at your first appointment.

                                    Informed Consent Form and Psychological Service Agreement.
Psychological service
The Health Psychology Clinic 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 is a necessary part of the pscyhological asssessment and treatment that is conducted.

Purpose of collecting and holding information
Personal information is kept securely and, in the interests of your privacy, used only by your psychologist and the authorised personal (e.g. administrative staff) or the practice (as necessary).

Your personal information is retained in order to document what happens during sessions, and enables your psychologist to provide a relevant and informed psychological service to you. Personal information is held in accordance with State and Territory privacy laws. You can obtain information from the clinic about how to access and seek correction of your personal information, and lodge a complaint about mangement of your personal information should you be dissatisifed with how your personal information is handled.

Consequence of not providing personal information
If you do not wish for your personal information to be collected in a way anticipated by this letter our privacy policy, The Health Psychology clinic may not be in a position to provide the psychological service to you. You may request to be anonymous or to use an alternative name (psuedonym), unless it is impracticable for The Health Psychology Clinic to treat you anonymously or if The Health Psychology Clinic is required or authorised by law to identify individuals. If using a pseudonym, you must pay full consultation fees at the time of the appointment and will not be eligible for a Medicare rebate.

Disclosure of personal information

All personal information gathered during the provision of the psychological service will remain confidential except when:
    1. it is subpoenaed by a court; or
    2. failure to disclose the information would in the reasonable belief of The Health Psychology
        Clinic staff place you or another person at serious risk to life, health or safety; or

    3. your prior approval has been obtained to
        a) provide a written report to another professional or agency. e.g., a GP or a lawyer; or
        b) discuss the material with another person, e.g. a parent, employer or health provider;
             or
        c) disclose the information in another way; or

    4. 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; or

    5. disclosure is otherwise required or authorised by law.  

Your personal information is not disclosed to overseas recipients, unless you consent or such disclosure is otherwise required by law. Your personal information will not be used, sold, rented or disclosed for any other purpose. 

Communication with other health professionals
The Health Psychology Clinic provides services to people experiencing health related problems and their carers. We attempt wherever possible to work as a team with your other health professionals. For clients accessing service under Medicare we are required to communicate with your GP about your treatment. However, in order to provide you with good team-based care, we also recommend you also provide us with consent to communicate with other health professionals you believe are relevant and important to inform about your psychological treatment (e.g. your medical specialist(s), specialist nurses, support coordinators, allied health professional). You will be asked to identify those people and provide us with their contact details.

*See NDIS Service Agreement for details
** Subject to annual change
If you are referred under Medicare you may be eligible for a rebate (see table above).

If referred under NDIS fees are charged at the standard rate. You will be billed separately for therapy reports (charged at NDIS Price Guide Rate) and asked to complete a NDIS specific service agreement. Out of office consultations for clients who are palliative or those with mobility issues upon request. Travel cost are negotiated depending on distance (up to 50 km) charged at NDIS Price Guide rate (current price  $214 per hour).

Fees are payable at the end of the session by cash, debit or credit card.  Fees are subject to change on an annual basis.

Cancellation Policy
If, for some reason you need to cancel or postpone your appointment, please give the Health Psychology Clinic at least 24 hours notice, otherwise you will be charged a 50% cancellation fee.

Availability for contact between sessions and emergency contact arrangements. 

The Health Psychology Clinic provides is a part-time practice. Appointments are offered to all clients on a monthly basis on dedicated clinic days. If your needs change and/or we cannot provide a safe service within these availability constraints this will be discussed with you and options for other services which can better meet your needs will be explored. If we refer you on to another provider we will notify your GP and provide details of the recommended alternative service to your GP so that they can facilitate a referral.  

Due to the part time nature of this practice we cannot provide a crisis service. We will notify of you any holiday periods or extended leave through automatic out of office emails and/or our answering service phone message. Outside of clinics you can leave a phone message or send us an email, and we will endeavour to reply as soon as practical. Please be aware this may take a few days especially during non-clinic weeks, at weekends or during holiday periods.  In the event of a mental health crisis you should do one of the following:

• Visit the Accident & Emergency department of your local hospital

• Phone the NSW Mental Health Access Line 1800 011 511

• Visit your GP practice

The following telephone crisis services are available 24hrs/7days and can provide support in the event of a crisis:

Lifeline 13 11 14

Suicide Callback 1300 659 467

Beyond Blue 1300 224 636

If a situation is life threatening ring Emergency Services on 000

Further information about receiving a telehealth service.

Requirement to provide contact details and location
As we will be working together by telehealth, I need to be able to contact support people in your locality should any safety issues arise. To access a service using telehealth you will need to provide the names and contact details of at least two people known to you and your GP before we commence treatment. These people may be contacted if not contacting them poses a risk of harm to you or another person, or in the case of a medical emergency where you require urgent medical attention. Because you may be in varied locations for you sessions, we will ask you to confirm your location at the commencement of each session and/or identify who is present in the room in order to maintain your privacy.

Privacy and data security in online communications
The privacy of any form of communication via the internet or a mobile device is potentially vulnerable and limited by the security of the technology. We use a secure telehealth platform which is compliant with privacy laws. We use secure electronic forms to and practice management systems to collect and store your personal information.  If there is a data breach involving your personal information which is likely to result in serious harm you will be notified and the breach reported to the Office of the Australian Information Commissioner in accordance with our obligations under the Privacy Act.

Wherever possible we aim to email for administrative purposes only such as setting up appointments, providing reading materials or resources following a session and issuing invoices etc. Invoices and receipts will be emailed as an attachment to an email. Please be aware that email communication may contain personal information and should be avoided for sensitive communication.

Use of therapy session materials
The Health Psychology Clinic will not make recordings of our sessions. If we wish to make a recording or use any material for other purposes (such as for training, or consultation with colleagues) we will always seek your written consent to do so.  We will ask you respect our privacy by agreeing not to make recordings of our sessions and not to use materials from our sessions for purposes other than therapy. lf you wish to record sessions or use session material for other purposes, you must seek written consent to do so. Storage of your health records, electronic records and paper records are kept in secure storage.

Technology Issues
Please be aware that you are responsible for any costs incurred in relation to the provision of your own internet service fees, software, hardware, and data usage associated with this telehealth service. There may be interruptions to the quality of the videocall which are beyond our control (e.g. internet speed/connection issues). Every effort will be made to address these. You can terminate treatment if telehealth is not right for you, or alternatively request a phone service, however please be aware that an audio and video link is required to receive a Medicare rebate (temporary exceptions may apply during the COVID pandemic).

Data Security 

At the Health Psychology Clinic, we take your data security seriously. We have compliance and regulation guidelines around data security which we must follow, and have made every effort to select software systems which are secure and compliant. The Health Psychology Clinic is an entirely paperless practice and all electronic records are password protected. We use Coreplus as our practice management software to store you clinical record, and Pin Payments to process and store billing information. Your credit card details for automatic payments are stored by Pin Payments, not The Health Psychology Clinic, and are deleted from Pin Payments when you complete treatment with us. In the event of a data breach which could lead to serious harm we are required by law to notify you of the notifiable data breach to the Office of the Australian Information Commissioner. If you have any questions about data security please do not hesitate to ask us. 

I,

have read and understand the Consent Form and Service Agreement.

I agree to the above conditions for the psychological service provided by: The Health Psychology Clinic

I hereby provide my consent for my therapist to communicate with the following people about my treatment:

Dr. Belinda Thewes, The Health Psychology Clinic   
Address: 14 Mirrabooka Ave, Moruya, NSW, Australia 2537

Ph: 0490 819 492                                                          Email:belinda@healthpsychclinic.com.au
Medicare Provider No: 5509831W                           www.healthpsychclinic.com.au

Consent form - Version Jan 1, 2024