Initial consultation form

 Male Female

 School Yellow Pages GP Friend

Client Information and Confidentiality

As part of providing a service to you, the clinician will need to collect and record personal information from you that is relevant to your current situation. This information will be a necessary part of the assessment and treatment that is conducted. You do not have to give all your personal information, but if you don’t, this may mean the service may not be able to be provided to you as may be required.

Purpose of collecting and holding information

The information is gathered as part of the assessment, diagnosis and treatment of the client and is seen only by the Clinician.The information is retained in order to document what happens during sessions, and enables the clinician to provide a relevant and informed service.

Access to Client Information

You are entitled to have access to the information about you kept on file, unless the relevant legislation provides otherwise. The clinician may discuss with you appropriate forms of access.

Confidentiality

All personal information gathered by the clinician during the provision of the service will remain confidential and secure within the practice except where:

  • 1.It is subpoenaed by a court, or if disclosure is otherwise required or authorised by law.
  • 2. Failure to disclose the information would place you or another person at serious and imminent risk; or
  • 3. Your prior approval has been obtained to
    a) provide a written report to another professional or agency. eg. a GP, or Lawyer or School; or
    b) discuss the material with another person (eg. a parent or employer), if disclosure is otherwise required or authorised by law.

Fees

The fees for the respective services are outlined on the Fee Schedule. These fees are payable at the end of the session.

Cancellation Policy

If, for some reason you need to cancel or postpone the appointment, please provide at least 24 hours’ notice, otherwise a 50% cancellation fee may be charged for the session.

Family/Medical/Behaviour Information (For clients 16 yrs and under)

Parents:

Step Parents (if applicable):

 both parents mother father grandparents guardians other

If parents are separated, then answer the following three questions:

Developmental History & Medical Information

 Yes No


Nature of the treatment, service provider and approximate duration

 Yes No

 Yes No

 Yes No

 Yes No Individual Group

Parental Observations

(Circle the letter if the behaviour occurs frequently)

Learning :

 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No

Behaviour and Social Issues :

 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No

Emotional Sensitivity

 Yes No
 Yes No
 Yes No
 Yes No
 Yes No

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