Telehealth Consent

Telehealth and Phone Consent Form

Telehealth refers to a videoconference consultation involving communication between you and your clinician using both a video and audio connection. This is similar to connecting with family, friends or business contacts using programs such as FaceTime or Zoom.

INFORMATION SPECIFIC TO TELEHEALTH

There are risks unique and specific to Telehealth, including but not limited to:

The possibility that therapy sessions via an online platform could be disrupted or distorted by technical failures or could be accessed by unauthorized persons.
Some presenting issues for clients may be less appropriate for internet or telephone counselling.
There may be decreased capacity for crisis intervention. Providing emergency contact details to assist in

times of crisis is important due to the different locations of therapist and client is particularly important.
Misunderstandings may arise due to the possible decrease of non-verbal cues being easily observed by

client and therapist.
Email and SMS messages may not be received.
Information may be forwarded inadvertently to a wrong address or number.
Other people may access clients’ email or SMS messages, for example, family members, friends, or

colleagues.
Psychologist’s records, including internet, email, SMS, or summary of telephone/telehealth communications,

may be subpoenaed.
Access to a device such as a smartphone, laptop, iPad, computer, with a camera, microphone and speakers;

and a reliable broadband internet connection is required.

CONFIDENTIALITY

All information shared during therapy will be kept strictly confidential. All records are stored in a secure location and are only used by your psychiatrist and the authorised personnel of the practice (as necessary). Information can only be released with written consent from the client.
The circumstances under which confidentiality can be broken without written consent include:

When the client is judged to be a potential risk to themselves or others
When a child discloses that they are being harmed
If the client discloses that they have committed/intend to commit a major crime
If the records are subpoenaed by a court of law

MISSED APPOINTMENTS OR APPOINTMENTS CANCELLED

Please allow at least two (2) business days notice if you are unable to attend your appointment. Appointment changes made with less than two (2) business days notice will incur a fee equal to 50% of the consultation fee. Cancellations with less than one (1) business day notice will incur a fee equal to 100% of the consultation fee. This fee must be paid within 5 days or all future appointments will be cancelled. Your cancellation notice is much appreciated, as this can

enable us to provide a service to those who are in need of an urgent appointment. Requests for waivers of our cancellation fee must be made in writing to the office manager and emailed to info@kookyclinic.com.au

FEES

Please refer to the current fee schedule.

BETWEEN SESSION CONTACT

Please contact reception by phone 07 3133 8018 or email info@kookyclinic.com.au where messages can be passed onto your clinician as they are unable to take calls during sessions. Your clinician is unable to do any scripts between appointments. Please book to see Dr Jane MacLeod at the Kooky Clinic, or your local GP.

PAYMENT

Payments can be made via the direct deposit details on the invoice or via credit card over the phone.

CONSENT

I have read and understood the above conditions and agree to them.

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Your legal name

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

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Signed by The Kooky Clinic
Signed On: April 14, 2020

Timestamp

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April 14, 2020 2:39 pm AEST

Telehealth Consent Uploaded by The Kooky Clinic - info@kookyclinic.com.au IP 1.132.110.199