As part of providing a psychological service to you, Dr. Paul Pusey and Associates needs to collect and record personal information from you that is relevant to your situation, such as your name, contact information, medical history and other relevant information as part of providing psychological services to you. This collection of personal information will be a necessary part of the psychological assessment and treatment that is conducted.

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

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
(a) provide a written report to another professional or agency. e.g., a GP or a lawyer; or
(b) discuss the material with another person, eg. a parent, employer or health provider; or
(c) disclose the information in another way; or

4. you would reasonably expect your personal information to be disclosed to another professional or agency (e.g. your GP) and disclosure of your personal information to that third party is for a purpose which is directly related to the primary purpose for which your personal information was collected; or

5. disclosure is otherwise required or authorised by law.

Where appropriate the service may be provided by telephone or videoconferencing. You are responsible for the costs associated with setting up the technology needed so you can access telehealth services. Dr. Paul Pusey and Associates will be responsible for the cost of the call to you and the cost associated with the platform used to conduct telehealth services.

To access telehealth consultations you will need access to a quiet, private space; and the appropriate device, i.e. smartphone, laptop, iPad/tablet, computer, with a camera, microphone and speakers; and a reliable broadband internet connection.

The privacy of any form of communication via the internet is potentially vulnerable and limited by the security of the technology used. To support the security of your personal information this practice uses Zoom which is compliant with the Australian standards for online security and encryption.

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 services for which telehealth is not appropriate or effective. Your psychologist will consider and discuss with you the appropriateness of ongoing telehealth sessions.

The cost for a 50 minute consultation will be the Medicare Rebate Fee for those individuals referred with a Mental Health Care Plan.

The cost for a 50 minute consultation without a Mental Health Care Plan will be $170.00 for an individual and $220.00 for a couple.

Please bring your Mental Health Care Plan dated prior to your appointment to your first consultation otherwise, you will be charged $170 for the session.

If for some reason, you need to cancel or postpone your appointment, please provide at least 48 hours notice.

The cancellation policy is as follows: Cancellations received with at least 48 hours notice will attract no cancellation fee. Cancellations received with less than 24 hours notice or less will be charged at the cost of the session. A reminder email/SMS will be sent to you at least 72 hours prior to your session time.

The attached Charter explains your rights as a client of a psychologist.

As a client of this practice you have a right to expect that:

1. You will be treated with respect

2. You will receive a clear explanation of the service you will receive

3. Your consent for any service provided will be sought prior to its commencement and during its progress

4. You will receive an explanation about the nature and limits of confidentiality surrounding the service

5. You will be clear about the goals that are being worked towards

6. You will receive a professional and competent service

7. An estimate of the number of sessions required to achieve your goals will be discussed

8. You will receive a service free from sexual or any other type of harassment

9. You will be shown respect for your cultural and language traditions.

I have been provided with information about the service including the limitations to privacy and confidentiality and I have agreed that in circumstances where the psychologist is concerned about my welfare and is unable to contact me permission is provided for the psychologist to contact the following person:

I,

have read and understood the information in this Consent Form and have discussed any outstanding questions with the practice/psychologist. I agree to the above conditions for telehealth psychological services to be provided by Dr. Paul Pusey and Associates.

A copy of this authority shall be as valid as the original and I understand that I can withdraw or amend my consent at any time.