Consent details

The purpose of this consent form is to ensure you are aware of relevant processes and procedures related to seeking psychological services.

Collection and storage of your information

Your counsellor will need to collect and record personal information that is relevant to your current situation. This information will be a necessary part of the psychological assessment and treatment that is conducted. This information is retained in order to document what happens during sessions, and enables your counsellor to provide a relevant and informed psychological service. All client information is stored in accordance with the Victoria Health Records Act (2001).


All information disclosed within sessions is confidential and may not be revealed to anyone without written permission except where disclosure is permitted or required by law. These situations include, but are not limited to: (a) when there is reasonable suspicion of abuse to a child or to a dependent or elder adult; (b) when a client is at risk of harm to others; (c) when a client is at risk of harm to themselves; or (d) when disclosure is required pursuant to a legal proceeding.

If you would like your counsellor to discuss your information with another health professional, parent or other relevant person they will request you complete a written consent form.

Emergency services

Please be aware that Inner Melbourne Clinical Psychology does not provide emergency services. If you require immediate assistance, please call 000 or for phone support call Lifeline on 13 11 14.

Session length

Sessions are approximately 50 minutes.

SMS reminders

SMS reminders are sent approximately 72 hours before appointments. Please do not respond to this reminder as this is an automated service that comes from a computer. If you need to cancel or reschedule your appointment call or email our Support Team (email is preferred).

48 hour cancelling and rescheduling policy

If you cancel or change your appointment within 48 hours, unless there is an emergency you will need to pay the full fee for this session. Regardless of whether an appointment is attended, our counsellors spend time planning client sessions, so we feel it is important that they are remunerated for this time. By giving us more than 48 hours of notice you allow us enough time to offer your appointment to other clients who may be on a waiting list to see the counsellor.

Fees and rebates

Your counsellor’s fees are $140.

Sessions with a counsellor do not attract a Medicare rebate, so if you have a Medicare referral you would not be able to use it for sessions with them.


Payment is required on the day of your session. You can pay with credit card or EFTPOS.

Telehealth services

Telehealth sessions are any sessions conducted via phone or online video.

Limitations of Telehealth services

The privacy of any form of communication via the internet is potentially vulnerable and limited by the security of the technology used.

A Telehealth consultation may be subject to limitations such as an unstable network connection which may affect the quality of the session. In addition, there may be some situations for which Telehealth is not appropriate or effective. Your counsellor will consider and discuss with you the appropriateness of ongoing Telehealth sessions.

Like face-to-face sessions it is important that Telehealth sessions are conducted in a private and confidential space (unless otherwise agreed upon), where you are the only person present.

Completing this form 

If you understand and agree with what is outlined above, please complete this form prior to your session with your counsellor. If you have any questions that you would like to ask before completing the form, please bring these along to your first session and your counsellor will be happy to answer them.

    Personal details

    First name


    Preferred name

    Date of birth


    Mobile number

    Email address

    Emergency contact details



    Mobile number