Intake Form- Informed consent and Confidentiality Terms.

Informed consent:
As part of providing a psychological service to you, I will need to collect and record
personal information about you. This information will be a necessary part of the
psychological assessment and treatment that is being carried out.
The information is gathered as part of the assessment and treatment of your presenting
concerns. The information is retained in order to document what happens during
sessions and enables SD Counselling to provide an appropriate and informed
psychological service. Any information collected will be stored securely. In accordance
with the AASW practice standards clinical supervision is received to ensure that SD
Counselling is providing an ethical and evidence-based service and therefore at times will
need to share deidentified information with my supervisor for this to occur.

Confidentiality:
All personal information gathered during the provision of the service will remain
confidential and secure except where:
1. It is subpoenaed by court
2. Failure to disclose the information would, in the reasonable belief, place you or
another person at serious and imminent risk of life or it appears a child has been
subjected to abuse or neglect
3. Your prior approval was obtained to
a) Provide a written report to another professional or agency e.g. your GP or Court
b) Discuss the material with another person e.g. a parent, employer
c) Disclose the information in another way
4. You would reasonably expect your personal information to be disclosed to
another professional or agency and disclosure of your personal information to that third
party is for the purpose directly related to the primary purpose for which your personal
information was collected
5. Disclosure is otherwise required or authorized by law

Cancellation:
To avoid charge, you are required to provide a minimum of 48 hours’ notice should you
need to cancel your appointment.

Privacy Policy

To view the Privacy Policy please click here.