Client information and Consent

Please read the information below, complete your details at the bottom of the page and hit the submit button.

Please note: If, after reading this form you are at all unclear about any of the information provided, please contact the psychologist prior to your appointment.

Psychological service

As part of providing a psychological service to you, your psychologist 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.

Purpose of collecting and holding information

Your personal information is gathered as part of your assessment and treatment, is kept securely and, in the interests of your privacy, used only by your psychologist and the authorised personnel of the practice (as necessary). Your personal information is retained in order to document what happens during sessions, and enables the psychologist to provide a relevant and informed psychological service to you.  

Consequence of not providing personal information

If you do not wish for your personal information to be collected then your psychologist may not be in a position to provide the psychological service to you.

Access to client information

At any stage you are entitled to access your personal information kept on file, subject to exceptions in the relevant legislation. The psychologist may discuss with you different possible forms of access.

Disclosure of personal information

All personal information gathered by the psychologist during the provision of the psychological service will remain confidential except when:

  1. it is subpoenaed by a court, or disclosure is otherwise required or authorised by law; or
  2. failure to disclose the information would in the reasonable belief of the psychologist place you or another person at serious risk to life, health or safety; or
  3. your prior approval has been obtained to
    • provide a written report to another professional or agency. e.g., a GP or a lawyer; or
    • discuss the material with another person, e.g. a parent, employer, health provider or third-party funder; or
    • disclose the information in another way; or
    • disclose 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.

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.


Provision of a telehealth service

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.  Mindscape Health Services 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 an appropriate device, i.e. smartphone, laptop, iPad, computer, with a camera, microphone and speakers; and a reliable internet connection.

Because you may be in varied locations for each of our videoconferences, I will require you to provide your location at the commencement of each telehealth 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 Coviu which is compliant with the Australian standards for online security and encryption.

Limitations of telehealth

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.

Use of therapy session materials

Mindscape Health Services will not make recordings of sessions or use material from sessions for purposes other than delivering a service to you. Mindscape Health Services will seek your written consent if your psychologist wishes to use material for other purposes (such as consultation with colleagues). Mindscape Health Services will ask you to respect your psychologist’s privacy by agreeing not to make recordings of sessions and not to use materials from sessions for purposes other than therapy. If you wish to record sessions or use session material for other purposes, you must seek your psychologist’s consent to do so.


The cost of a 50-minute consultation is $185, payable at the end of the session by cash, EFTPOS or credit card.

Between 1st April 2020 and 30th September 2020, patients with a valid referral (e.g. a care plan) can be bulk billed for telehealth/telephone if they provide Medicare Card details as well as consent to bulk bill in each session.  If consent to bulk bill is not provided, the usual fee for service will be applied. 

Cancellation Policy

If, for some reason 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 $92.50. 

Preferred Title (e.g. Mr, Mrs, Ms, Miss, Dr, etc)
First name
please type day / month / year
Street name & No
Suburb / town
primary telephone number
secondary tel no - if you have one
please type Day / Month / Year
their telephone details
their relationship to you
their telephone details
their relationship to you
GP's name
GP's telephone number
GP's address
Full name as it appears on the card
card number
The number to the left of your name (Individual Reference Number [IRN] )
Expiry date - please type month / year