CONSENT FORM

This form lets you tell us who we can speak with, how we can contact you,

and how your information may be used and shared.

It is important all boxes are ticked to access the detail even if you are answering "No"

Are you completing this for yourself or as a parent/guardian? *

SelfParentGuardian

Child's Name *

First Name *

Last Name *

Date of Birth *

Mobile Number

Email Address

A. CONSENT FOR PSYCHOLOGICAL SERVICES

As part of providing a psychological service to you Jon Grainger Psychology needs to collect and record personal information fromyou that is relevant to your situation, such as your name, contact information, medical history and other relevant information as partof providing psychological services to you. This collection of personal information will be a necessary part of the psychologicalassessment and treatment that is conducted.

A detailed description of how your personal information is managed, how you can access your personal information, and how tolodge any concerns or complaints about this service or how your personal information is managed must be provided to you by yourhealth professional on request.

B. DISCLOSURE OF PERSONAL INFORMATION

Personal information gathered as part of this service will remain confidential except when:

1. it is subpoenaed by a court; or

2. failure to disclose the information would place you or another person at serious risk to life, health or safety; or

3. your prior approval has been obtained to

provide a written report to another professional or agency, eg. a GP or a lawyer; or
discuss the material with another person, eg. a parent, employer or health provider; or
disclose the information in another way; or
you would reasonably expect your personal information to be disclosed to another professional or agency (e.g. your GP) anddisclosure of your personal information to that third party is for a purpose which is directly related to the primary purpose forwhich your personal information was collected; or
disclosure is otherwise required or authorised by law.

C. CONSENT AUTHORISATION - Please tick EVERY box

⚠️ Important for Your Care - To provide safe, coordinated and effective support, we rely on the information you provide in all consent areas. Please review each section carefully and select your preferences. PLEASE TICK EVERY BOX TO REVIEW AND RESPOND *

Your Information Sharing Preferences (Including GP Updates)Telehealth ConsentAssessment & Supervision ConsentCommunication & RemindersFinancial & Billing ConsentLegal & Court Related

SHARING INFORMATION PERMISSIONS

GP CONSENT

GP Name *

Practice Name *

Practice Email Address (if known)

PSYCHIATRIST/PAEDIATRICIAN CONSENT

Psychiatrist / Paediatrician Name *

Email Address (if known)

NDIS SUPPORT COORDINATOR CONSENT

Support Co-ordinator Name *

Email Address *

Phone Contact

What Information can we share with your Coordinator?

Any Limits on what we can share?

NDIS PLAN MANAGER CONSENT

NDIS Plan Manager Name *

NDIS Plan Manager Email Address

What information can we share with them?

Any limitations on what we can share with them?

SUPPORT WORKER CONSENT

Support Worker Name

Support Worker Email Address

Support Worker Phone Number

What information can we share with them?

Any limits on what we can share?

SCHOOL / TEACHER / SCHOOL COUNSELLOR CONSENT

School *

Teacher Name *

Email Address

Phone Contact Number

What information can we share with them?

Any limits on what we can share?

LEGAL REPRESENTATIVE CONSENT

Legal Representative Name *

Legal Firm *

Email Address

Phone Contact

What information can we share with them?

Any limits on what we can share?

INSURER & CASE MANAGER CONSENT

Insurer Name *

Case Manager Name

Email Address

Phone Contact

What information can we share with them?

Any limits on what we can share with them?

FAMILY MEMBER / PARTNER / CARER CONSENT

Name of Family Member/Partner/Carer *

Relationship

Email Address

Phone Contact

What information can we share with them?

Any limits on what we can share

OTHER PROFESSIONAL CONSENT

Other Professional Name

Organisation

Email Address

Phone Contact

What information can we share with them?

Any limits on what we can share?

TELEHEALTH CONSENT

At times, your psychologist may offer sessions by telephone or secure videoconference.

Telehealth provides a convenient and effective way to continue therapy if you are unable to attend in person. For example, if you are unwell, travelling, or unable to come into the office at short notice. This helps to maintain continuity of care and minimise any disruption to your progress.

You are responsible for any costs associated with setting up the technology needed to access telehealth services (for example, your own device or internet data). Jon Grainger Psychology will cover the cost of the call and the secure telehealth platform.

To access telehealth consultations, you will need a quiet, private space and a suitable device such as a smartphone, tablet, or computer with a camera, microphone, and speakers, along with a stable internet connection.

We use platforms that meet Australian standards for online security and encryption, however, please be aware that any internet-based communication carries some inherent privacy limitations.

While telehealth is a safe and effective option for most people, it can occasionally be affected by factors such as poor internet connection. Your psychologist will always discuss with you whether telehealth is suitable for your needs and whether in-person sessions may be more appropriate at any time.

Do you consent to Telehealth *

YesNo

ASSESSMENT & SUPERVISION CONSENT

Do you consent to Psychological Assessment

YesNo

Covers both general assessments used during therapy and formal assessments (like ADHD or Autism) when needed.

Do you consent to questionnaires & online testing

YesNo

Questionnaires and online testing provide helpful insight for your psychologist. Your data is encrypted and only accessed by authorised clinicians.

Is your treating clinician a provisional psychologist

YesNoUnsure

I consent to my provisional psychologist being supervised by a Board-approved supervisor who may review my case notes and discuss my care for training and quality purposes

Do you consent to sessions being audio/video recorded for supervision/training (if ever requested)?

Yes No

COMMUNICATION & REMINDERS

I consent to SMS reminders about appointments *

I consent to emails about appointments, invoices and reports *

I consent to voicemails being left on my phone about appointments *

I consent to receiving reports via email *

How would you prefer we communicate with you instead?

FINANCIAL & BILLING CONSENT

I have discussed with the admin team or reviewed the current fee schedule and cancellation policy and understand the requirements. *

I authorise Jon Grainger Psychology to invoice my Plan Manager/NDIA or myself for services provided under my NDIS Plan and as per the Service Agreement. *

I authorise Jon Grainger Psychology to send invoices and clinical reports (where required) to my Insurer/Third Party *

LEGAL & COURT RELATED

I understand my file may be subpoenad if my matter becomes involved in legal proceedings *

I understand additional fees may apply for reports, court attendances and communication with lawyers or insurers *

DECLARATIONS & SIGNATURE

I have read and responded to all consent items above (Item C - CONSENT AUTHORISATION) to ensure my care and communication preferences are accurately recorded. *

I confirm the information provided is accurate *

I understand I can withdraw or change consent at any time by completing the form again or notifying the practice in writing *

Signature *

Draw signature|Type signatureClear

Date *

Full Name of Person Completing this Form *

Comments