Existing Client 12 Month Consent Form

Client Name *

First

Last

Date Of Birth (D.O.B) *

Where have you been attending? *

Do you still give consent to engage in services at PsychSolutions Health and Wellbeing? *

Yes
No

Has there been any changes in your contact details in the last 12 months *

Yes
No

Please provide the updated contact details below:

Name

Address

Phone

Email

Have your Medicare details changed in the last 12 months? *

Yes
No

Please provide the updated Medicare details below:

Medicare Number

Expiry Date

Number on Card

If your child is our client, are there any changes to any parenting/custodial orders in the last 12 months? *

Yes
No
N/A

If Yes, please discuss this with your clinician.

Have your payment details or billing information changed in the last 12 months? *

Yes
No

Please contact your local office on:
Orange 6360 3551
Bathurst 6331 8865
Dubbo 6882 7551

I agree

I acknowledge and understand that everything I share with my clinician in our sessions is kept confidential. However, there are some important exceptions to this confidentiality:

1. Risk of Harm: If your clinician believes there is a serious risk that you might harm yourself or someone else, they are legally required to take steps to prevent this, which may include breaking confidentiality.

2. Legal Requirements: If your clinician is subpoenaed by a court, they may be required to disclose information shared during our sessions.

3. Child Protection: If your clinician has reasonable grounds to suspect that a child is at risk of harm, they are obligated to report this to the appropriate authorities.

4. Consultation with Other Professionals: Occasionally, your clinician may discuss aspects of your case with other professionals for supervision or consultation purposes. In these cases, they will protect your identity and ensure your privacy is maintained.

If you have any questions or concerns about these limits, please talk to your clinician.

Orange

Bathurst

Dubbo

Maitland