INFORMED CONSENT
By signing this document and starting consultation with your treating psychologist you agree that you provide consent to this. You are aware that you can end this service at any time. You have been explained the process and allowed to ask any quetsions of your treating psychologist to ensure your informed consent to consultation. Cherilee Botha Psychology cannot be held liable for any phsyical injury or loss whatsoever while engaging via telehelath or at the practice.
I agree that I have provided informed consent *
THIRD PARTY REPORTS/ FORMS/ ASSESSMETN REQUESTS/ DATA SHARING
Our psychologists' first priority and main focus is on providing ethical and evidence based therapeutic interventions to their clients; reports/forms are not the main focus nor priority. Report writing / Form completions are very time and resource intensive and as such, can significantly impact our psychologists appointment availability (which is better used for the treatment and management of our clients). If a short form / letter is required, your psychologist will complete that with you in your session time. More detailed and comprehensive reports/forms are billed for depending on the time taken to complete the report and are billed at the standard hourly rate. Unless otherwise stipulated, the invoice for this work is to be paid by the client (who can then submit the invoice to their respective Third party for reimbursement). Finally, in order for a comprehensive and well-thought out report to be completed, our psychologists require advanced notice and time - please be mindful of your Third party expectations / timelines for these types of reports and advise your psychologist in good time. Under NO circumstances are we able to do a 'once off session' for a report/form to be completed.
I agree to the terms and conditions of the above Policy on Letter / Report writing *
Please note: If, after reading this form you are at all unclear about any of the information provided, please contact us prior to your appointment.
PRIVACY POLICY
Personal Information
As part of providing a psychological service to you, Cherilee Botha Psychology 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 that would be relevant to the provision of psychological services to you. This collection of personal information will be a necessary part of the psychological assessment and treatment that is conducted.Purpose of Collecting and Holding Information Your personal information is gathered as part of your assessment and treatment, is kept securely and, in the interests of your privacy, used only by your psychologist and the authorised personnel of the practice (as necessary). Your personal information is retained in order to document what happens during sessions and enables the psychologist to provide a relevant and informed psychological service to you. Please contatc Cherilee Botha Shoul dyou wish to access and/or seek correction of your personal information, and how to lodge a complaint about our management of your personal information.
Consequence of not providing Personal Information
If you do not wish for your personal information to be collected in a way anticipated by this contract or the Privacy Policy, your psychologist may not be in a position to provide the psychological service to you. You may request to be anonymous or to use a pseudonym, unless it is impractical for your psychologist / Cherilee Botha Psychology to deal with you or if your psychologist / Cherilee Botha Psychology is required or authorised by law to deal with identified individuals. In most cases it will not be possible for you to be anonymous or to use a pseudonym. Access to Personal Information At any stage you are entitled to access your personal information kept on file, subject to exceptions in the relevant legislation. The psychologist may discuss with you different possible forms of access.
Disclosure - Personal Information
All personal information gathered by the psychologist during the provision of the psychological service will remain confidential except when: 1. it is subpoenaed by a court, or disclosure is otherwise required or authorised by law; or 2. failure to disclose the information would in the reasonable belief of the psychologist 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, health provider or third party funder; or c) disclose the information in another way; or d) disclose 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. Should an individual other than the Client attempt to collect, change or request details on behalf of the Client, prior written approval will need to be obtained from the Client and proof of ID of the individual requesting the information. Your personal information is not disclosed to overseas recipients, unless you consent, or such disclosure is otherwise required by law. Your personal information will not be used, sold, rented or disclosed for any other purpose. In the event that unauthorised access, disclosure or loss of a client’s personal information occurs, Cherilee Botha Pyschology will activate its data breach plan and use all reasonable endeavours to minimise any risk of consequential serious harm. Cherilee Botha Psychology may use NovaNote to support therpay note documentation during sessions. The practice follows ethical guidlenes in how notes and personal information is managed to ensure confidendiality.
I agree to the terms and conditions of the above Privacy Policy Agreement *
CANCELLATION POLICY
Before cancelling an appointment, consider if a Telehealth appointment is an option for you. We ask that our clients give us at least 48 hours’ notice of the business week. Cancellation Fee Structure:- Less than 48 hours in a business week: incurs a 50% fee of the current session price.- Less than 24 hours in a business week: incurs a 100% fee of the current session price.- Not arriving for your session incurs a 100% fee of the current session price. (A Business Week is Monday-Friday and does not include the weekends or Public Holidays.) Clients are responsible for managing their own bookings / appointment schedule. Cherilee Botha Psychology does try to remind clients of booked sessions as a courtesy, or cancel sessions within the correct timeframe if needed, but in the end it cannot be held responsible. The onus is on the client to make, keep and cancel sessions according to their needs. We understand that the unexpected happens to us all. If a client is experiencing an emergency, please contact our rooms immediately to discuss it with us or leave a message and we will be able to make the relevant actions. It will be to the discretion of management if a fee will be charged. Please note that an emergency is considered to be extenuating circumstances outside of your control, which gave you no choice but to cancel your session with us. Should the client be aware of an illness / emergency more than 48 hrs (of the business week) before the session time and fail to cancel the appointment within the requested time frame, fees may still be incurred. Should a client develop a pattern of cancellations or have recurring late cancellations this will be discussed between yourself and your treating psyhcologist. Cherilee Botha Psychology will consider any bookings made or kept after the changes / updates to act as an acceptance of an updated policy. Due to legislation, under no circumstances can we submit a cancellation / DNA fee to Medicare or a Private Health Fund. We appreciate and encourage good communication so should you have any questions, please get in touch.
TELEHEALTH POLICY
Privacy
Clinicians conduct Telehealth Sessions in a private setting / location to protect your privacy during the therapeutic session. Your Psychologist will treat your information in confidence and with respect. Any information shared will be with your consent. No Telehealth Session is recorded. We use Cliniko as our service provider for all Telehealth Sessions. All Cliniko servers are based in Australia and therefore compliant with the Australian Privacy Act.
Software / Data
No special software or apps are needed only the Cliniko meeting invitation link which is contained within your confirmation/reminder email. Cherilee Botha Psychology will not be held responsible for any time lost trouble shooting any issues that may arise during the call unless directly a result of a malfunction of the Clinicians hardware or software. It is recommended to check that your preferred browser is updated and current. Data usage for the video call is covered by your service provider so please make sure you have enough data to complete your session.
Environment
Our recommendations for your Telehealth setting / location is for privacy, comfort and no distractions. Our Telehealth sessions are conducted the same as a Face-to-Face session. We ask that you give the session your full attention and limit or avoid doing other activities while in session. We want to ensure you get the most out of each session. Choose a room with good lighting while trying not to sit with a bright window behind you as this will create glare or a white-out and the psychologist will not be able to see you clearly. Make sure that the area you have chosen receives good signal to avoid potential interruptions during your session. In the event that your psychologist is concerned about your safety or the safety of others, the usual limitations and protocols for ensuring your safety and the safety of other apply.
Connecting and Fees
All Telehealth Sessions are invoiced and paid for before the session commences or at the end of the session. It is important to note that a client is not eligible for Medicare rebates if they are not on Australian soil (i.e. are Overseas) at the time of the Telehealth session. At the time of your Telehealth Session, the Clinician will be waiting online, ready for you to click on and connect via the Cliniko Link sent to you. If you do not have the link or cannot find it, please contact us immediately to send the link through to you. The psychologist will make 2 attempts to contact you and the frontline staff will attempt to call you incase you are struggling to connect to be able toa ssist you. All Telehealth sessions are conditional to the DNA and Late Cancelation policy. If we are unable to reach you, we will invoice you for our standard Did Not Attend (DNA) fee according to our Cancellation Policy.
I agree to the terms and conditions of the above Telehealth Policy Agreement *
FEEDBACK INFORMED THERAPY
I understand that Cherilee Botha Psychology uses a Feedback Informed Therapy (FIT) framework as part of their quality assurance measures with the goal to help clients achieve their best potential outcomes. I accept that the information gathered is stored on servers that are GDPR compliant. I acknowledge that I am able to review the FIT information on the Cherilee Botha Pscyhology website if needed. I understand that participation is voluntary and I can choose not to participate if I prefer. If I am unsure about the relevance of FIT to my treatment planning, or if I have any other queries about FIT, I will discuss these questions with my psychologist. *
TYRO HEALTH ONLINE PAYMENT SYSTEM
General Payments
Payment for initial and subsequent sessions with one of the Cherilee Botha Psychology Psychologists is required through a secure online payment system: Tyro Health. Bank card details are collected either directly from a client by a frontline staff member or through a payment link sent to your mobile device and is then encrypted and saved into Tyro Health for all future payments. (Security details are outlined in the next section) For sessions within office hours, payments are automatically deducted on your arrival for the session. For all sessions outside of office hours, payment is automatically deducted through Tyro Health no later than 6pm of that same day and payment is recorded for the Psychologist's benefit. This allows your Psychologist to seperate the financial and clinical relationship. Your Psychologist will be able to focus on your treatment rather than the payment reconciliation. Tyro Health Security Features Tyro Health uses stringent data and security protocols for storing payment details. To learn more, please follow the link: Tyro Security. Once your details are initially entered and captured in Tyro Health, they are tokenised which means they are not visible to anybody within the practice or at Tyro Health. If payment details need to be altered or updated, they must be completely re-entered as a further security measure, this is because tokenised payment details cannot be edited for added security.
Late Cancellation / Unattended Sessions
Due to the increasing number of clients cancelling with insufficient notice, booking and then not attending, or attending but having already exhausted their NDIS, Workcover or other funds, we now require bank card details to be saved on the Tyro Health platform and will automatically debited to cover such events. In the event of insufficient funds, we reserve the right to engage debt collection services.
I agree to the terms and conditions of the above Online Payment Policy Agreement *
CONCLUSION AND CONSENT
I have read and understood this consent form. I agree to the above conditions for the psychological services provided.
By signing, I understand that I am entering into a legal agreement between myself and the practice. I confirm that above information I have provided is true, complete and accurate. I agree and consent to the Cherilee Botha Psychology Policies described herein, as well as those terms marked with *.
