Informed Consent Form (Child)

CONSENT

Informed Consent Form (Child)

Privacy Note

In order to develop an understanding of your presenting difficulties, the Receptive Mind clinician will need to collect and record personal information from you that is relevant to support your needs. The information collected will help determine:

• what your difficulties and needs are and how these can be addressed,
• whether you are eligible to apply for additional resources, and
• what services you may be able to access.

Confidentiality

All information and records gathered by the Receptive Mind clinician during the provision of the counselling service will remain confidential and secure except when:

• It is subpoenaed by a court, or
• You or another person (including your children) might be at risk of harm; or
• Your prior approval has been obtained to
• provide a written report to another professional or agency (e.g., a medical specialist, GP, a psychiatrist, rehabilitation coordinator etc) or as listed below:
• discuss with another person whom you have provided consent for; or
• discuss with EAP providing agency where/if necessary
• disclosure is otherwise required by law.

TeleHealth

Engaging in TeleHealth services includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive live audio, video, or data communications. It is important to understand that TeleHealth also involves the communication of my medical/mental information, both orally and virtually, to health care clinician/s located in Australia. It is again important that you understand that the following rights and responsibilities abides with respect to TeleHealth principles that:

• I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
• The laws that protect the confidentiality of my medical information also apply to TeleHealth. As such, I will need to attest that I am in a private, non-public, secure place, and alone for each of my TeleHealth sessions.
• I will not record the session and will be informed if recorded by the clinician.

I AGREE to ABIDE by:

• Actively being involved in working out with my treatment plan; or
• If I am intoxicated during a clinic visit, the session will be rescheduled to another time; or
• I will only take medications prescribed by treating team not from other sources; or
• I agree to contact/inform any GP, the CATT Team etc. if I experience symptoms of psychosis, paranoia or feelings of self-harm.

If you have any further questions, please contact Receptive Mind Services on 0400 345 045 during peak hours, however:

please be aware that there are limitations to the services provided by Receptive Mind clinician during afterhours. If you have an urgent matter concerning my mental health and wellbeing, please contact your community mental health team or lifeline on 131114.

Clinicians will try to arrange appointments to fit in with times that are convenient to you. On occasions an emergency may require Clinicians to reschedule. Sometimes unforeseen circumstances lead to the need to cancel or reschedule an appointment. Under Care Management and Cancellation Protocol you are required to give 24-hours-notice of cancellations and requests to reschedule so another patient can be offered that time, you will incur the session fees.