business%20card%20logo_edited.jpg

Counselling Consent Form

No gap fee to pay

Kylie Bell Counselling, is committed to providing you with the highest level of
service and confidentiality and this includes protecting your privacy. KBC is bound by the
Commonwealth Privacy Act 1988 and the Privacy Amendment (Private Sector) Act 2000, which
outline the principles concerning the protection of your personal information.


Duty of Care
Please note that KBC have a duty of care to you as our client to ensure your safety and the
safety of those around you. If we have concerns for your welfare, your appointed emergency
contact will be advised and may be asked to collect you from the service to transport you to the
most appropriate service to suit your needs (eg the nearest hospital emergency department if
you are feeling suicidal). Please note that if you choose not to appoint an emergency contact,
or we are unable to make contact with your appointed emergency contact person, we may be
required to contact an ambulance on your behalf if we have concerns for your immediate safety.
In these instances, you will be liable for any ambulance fees incurred.
Collection, exchange and disclosure of information
To provide you with the best possible health care, we may need to communicate about your
relevant history, diagnoses and treatment. If you were referred to KBC by another service,
communication may also occur between the referrer and us. By attending KBC you consent to
this communication. This information will remain confidental between you and your GP, referrer
and KBC. This communication will assist in the ongoing coordination, improvement and
maintenance of your health and wellbeing.

Collection, exchange and disclosure of information

To provide you with the best possible health care, we may need to communicate about your
relevant history, diagnoses and treatment. If you were referred to KBC by another service,
communication may also occur between the referrer and us. By attending KBC you consent to
this communication. This information will remain confidental between you and your GP, referrer
and KBC. This communication will assist in the ongoing coordination, improvement and
maintenance of your health and wellbeing.


Information management
In accordance with the privacy legislation (mentioned above) all information collected about you
is confidential and will be stored in a secure manner using data management software.
Information is stored in securely protected data centres in Australia. Any paper copies of
information such as Client Registration Forms or questionnaires are uploaded to this data
management system and then destroyed as soon as possible. You may request to see
information held about you. Information will only be disclosed to other organisations with your
consent, except where KBC is legally obliged to release the information such as in the following
situations:
- Subphoena: where all or part of your records are requested as part of a court order;
- Ethical/Duty of Care: where there is a concern of harm to self or others.

Please be aware that requests for information may incur a fee.


Cancellation Policy
If you need to cancel your counselling session please allow at least 24 hours notice. The
session time is put aside for you and cannot be filled with another client at short notice. If you
are able to cancel your session with at least 24 hours notice then there will be no outstanding
cost to you.


Your sessions are fully funded by Medicare’s Better Access to Mental Health Care Initiative. If
you cancel your session less than 24 hours before it is due to start then KBC cannot recoup the
payment from Medicare nor fill the session with another client. Our policy therefore is that if
you wish to attend a subsequent session after the one you missed without giving at least 24
hours notice, then you will need to pay the amount of the Medicare rebate to us in order to
secure your next appointment. This amount will be advised when you contact us to make your
next booking.


If, after reading each of the statements above, you are happy to progress with treatment with
KBC, please indicate that you consent by signing below.
- I understand that I must pay for my appointment at the date and time of the appointment.
- I understand that I will be liable for any emergency services costs which may be incurred as a
result of KBC acting on their duty of care requirements (eg ambulance fees in the event that I
am feeling suicidal and need to be transported to hospital).
- I agree that information about my health and wellbeing may be communicated between my GP,
referrer and KBC where required to assist in the management of my health care.
- I am aware that I have the right to change or retract my consent for future services with KBC.
- I am aware that I have the right to access or refuse an interpreter when using KBC.


Thank you for taking the time to read and consider this consent form.