Consent details

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

Relationship therapy works best when the focus of sessions is on your relationship. When working with you, it is expressly understood that the client is both your relationship and each of you as individuals. In order to maintain fidelity to both of you and to your relationship, your therapist asks for your consent in relation to the following:

No secrets policy

When a couple enters into counselling, it is considered to be one unit. This means that your therapist’s allegiance is to the couple as a unit, and not to either partner as individuals. In this way both partners can feel safe. This means that your therapist will not hold secrets for either partner. This policy prevents, to the extent possible, a conflict of interest in which an individual’s interests may clash with the interests of the unit being treated.

On occasion your therapist may need to counsel partners individually. If so, the session is still considered as part of the couple’s counselling relationship. Information disclosed during individual sessions may be relevant or even essential to the proper treatment of the couple. If an individual chooses to share such information with the therapist, the therapist will offer the individual every opportunity to disclose the relevant information and will provide guidance in this process. If the individual refuses to disclose this information within the couple’s session, the therapist may determine that it is necessary to discontinue the counselling relationship with the couple. If there is information that you would like to address within a context of individual confidentiality, your therapist will be happy to provide referrals to other professionals who can provide concurrent individual therapy. This policy is intended to maintain the integrity of the couples counselling relationship.

Court proceedings/subpoena of records

It is understood that the purpose of couples therapy is for the amelioration of distress within a relationship. Therefore, it is expected that neither person in the couple would use information revealed during the therapy process against the other party in a judicial setting of any kind, be it civil or criminal. Likewise, neither party shall for any reason attempt to subpoena the therapist’s testimony or therapy records/notes to be presented in a deposition or court hearing of any kind for any reason, such as a divorce case.

Collection and storage of your information

As part of providing a psychological service to you, your psychologist 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 psychologist to provide a relevant and informed psychological service. All client information is stored in accordance with the Victoria Health Records Act (2001).

Confidentiality

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

In order to maintain their registration psychologists are required to engage in professional supervision and peer consultation throughout their career. This may involve discussing clients in a non-identifiable way.

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

Couples sessions are approximately 50 minutes, unless you’ve booked a 90 minute first session.

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).

Cancelling or rescheduling appointments

Our clinic has a 48-hour cancellation and rescheduling policy. This means if you cancel or change your appointment within 48 hours, unless there is an emergency you will be charged the full fee for this session. 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 waiting lists. Our reception closes at 5pm on a Friday, so for Monday appointments please call by Friday morning. Please note that Medicare or private health insurance does not issue rebates for unattended appointments.

Fees 

As of the 1st of February 2021 your psychologist’s fees for 50 minute sessions are $210 during business hours and $225 after hours (before 9am, after 4pm and on weekends). For 1.5 hour sessions your psychologist’s fees are $245 during business hours and $260 after hours.

Payment

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 psychology session. In addition, there may be some situations for which Telehealth is not appropriate or effective. Your psychologist 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 psychologist. 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 psychologist will be happy to answer them.

Consent and registration form

    PARTNER ONE

    Personal details

    First name

    Surname

    Preferred name

    Date of birth

    Full address

    Mobile number

    Email address

    Emergency contact details
    Please make sure you provide the details of someone other than your partner. For example, a friend, sibling or parent.

    Name

    Relationship

    Mobile number

    PARTNER TWO

    Personal details

    First name

    Surname

    Preferred name

    Date of birth

    Full address

    Mobile number

    Email address

    Emergency contact details

    Name

    Relationship

    Mobile number