Telehealth Consent Form


As part of providing a psychological service to you, the psychologists and staff at Clinical Psychology Victoria need 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 on request.


Personal information gathered as part of this service will remain confidential except when:
1. it is subpoenaed by a court; or
2. failure to disclose the information would 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, eg. 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.


Clinical Psychology Victoria staff and psychologists will not make recordings of our sessions or use material from our sessions for purposes other than delivering a service to you. We will seek your written consent if we wish to use material for other purposes (such as consultation with colleagues).
We ask you to respect the privacy of Clinical Psychology Victoria staff and psychologists by agreeing not to make recordings of our sessions and not to use materials from our sessions for purposes other than therapy. If you wish to record sessions or use session material for other purposes, you must seek our consent to do so.


Where appropriate the service may be provided by telephone or videoconferencing. You are responsible for the costs associated with setting up the technology needed so you can access telehealth services. Clinical Psychology Victoria 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.
Because you may be in varied locations for each of our videoconferences or phone calls, we will require you to provide your location at the commencement of each session.
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 FaceTime (if you have an apple device like a Mac Computer, iPad, newer iPod, or iPhone) or doxy.me (no download needed - https://doxy.me/) 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.


The cost of a consultation (approximately “50” minutes) is in line with the APS Recommended Fees (https://cpvic.com.au/cpv-documents-for-clients/) which is payable at the time of the session by (phone, invoice / direct deposit). We will accept the maximum amount that a third party payer provides as full payment. For Medicare And private clients our fee is $180 (for Clinical Psychologists) or $140 (for Clinical Psychology Registrars). Your psychologist will discuss with you your eligibility for Medicare or other compensable funding.


If you need to cancel or postpone your appointment, please give the psychologist at least 24 hours notice, otherwise you will be charged a cancellation fee of $50.


The Charter explains your rights as a client of a psychologist and is available at https://cpvic.com.au/cpv-documents-for-clients/.


I have been provided with information about the service including the limitations to privacy and confidentiality and I have agreed that in circumstances where the psychologist is concerned about my welfare and is unable to contact me permission is provided for the psychologist to contact the following two people:

Name (required):
Email:
Telephone (required):
Relationship to you (required):

PartnerFamilyFriendWork ColleagueNeighbourMedical ProfessionalOther

They are aware of this request and understand what is being asked of them (required)?

YesNo

Name (required):
Email:
Telephone (required):
Relationship to you (required):

PartnerFamilyFriendWork ColleagueNeighbourMedical ProfessionalOther

They are aware of this request and understand what is being asked of them (required)?

YesNo


First Name Last Name

If you don't have one, you can use a trusted person's email

SelfParent / GuardianPartnerFamilyFriend


First Name Last Name

I have read and understood the information in this Consent Form and have discussed any outstanding questions with the practice/psychologist. I agree to the above conditions for telehealth psychological services to be provided by (required) .