Counselling Consent Form
Kylie Bell Counselling (KBC) 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 confidential between you and your GP, referrer and KBC. This communication will assist in the ongoing coordination, improvement and maintenance of your health and wellbeing.
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 or stored in a locked filing cabinet and returned to you at your next session/posted to your postal address. 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:
- Subpoena: 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.
If you need to cancel your counselling session please allow at least 24 hours’ notice. When sessions are cancelled with at least 24 hours’ notice you will be refunded 100% of the session cost. If you cancel your session less than 24 hours before it is due to start you will be refunded 20% of the session cost.
Non attendance without prior cancellation will accrue the full fee. The reason for this is that the time allotted is your time which we make available solely for you and your needs. The session can’t be offered to another client if the appointment is not attended without prior cancellation or is cancelled with less than 24 hours’ notice.
If, after reading each of the statements above, you are happy to progress with treatment with KBC, please indicate that you consent by signing and dating 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.