Child Referral Form

Confidentiality

This gathering of information is a necessary part of the assessment, diagnosis, and treatment procedure, and is seen only by the Clinician. All personal information gathered by the clinician during the provision of the service will remain confidential and secure within the practice except where:

• A written report is compiled and consent is given to forward the report to another professional, workplace or agency
• Failure to disclose the information would place you or another person at ‘risk of harm’
• Your prior approval has been obtained
• Discussion of the material is required with another person

Authority to Release information

By signing this form, you are giving Educational Case Management Pty Ltd (ECM) consent to obtain relevant medical records, reports and/or statements from your treating medical practitioner, allied health professional and/or other professional persons involved in your care. The purpose of collecting this health information is to assist ECM practitioners in supporting you and determining ‘best practice’

Privacy Consent

Therapy Service

As part of providing a service to you, Educational Case Management Pty Ltd - Psychology, Occupational Therapy and Speech Pathology, 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 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.

A more detailed description is provided in the practice’s “Privacy policy for management of personal information”, by accessing the Privacy Policy on our website or by contacting Educational Case Management Pty Ltd.

The Privacy Policy contains information about how to access and 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 letter or the Privacy Policy, Educational Case Management Pty may not be in a position to provide the allied health service to you. You may request to be anonymous or to use a pseudonym, unless it is impracticable for Educational Case Management Pty to deal with you or if Educational Case Management Pty 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, however if Educational Case Management Pty Ltd agrees to you being anonymous or using a pseudonym, you must pay consultation fees at the time of the appointment.

Access to client information

At any stage you are entitled to access your personal information kept on file, subject to exceptions in the relevant legislation. The Clinician may discuss with your different possible forms of access.

Disclosure of personal information

All personal information gathered by the clinician during the provision of the allied health service will remain confidential except when:

1. it is subpoenaed by a court; or

2. failure to disclose the information would in the reasonable belief of the (Educational Case Management) place you or another person at serious risk to life, health or safety; or

3. your prior approval has been obtained to

   1. provide a written report to another professional or agency. e.g., a GP, NDIS or a lawyer; or

   2. discuss the material with another person, e.g. a parent, employer or health provider; or

   3. 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.

Cancellation Policy

Unfortunately, we need to charge a cancellation fee if you do not attend an appointment, or if you need to cancel after 3pm on the day prior to scheduled appointment. We have a wait list; hence your appointment could be allocated to someone else if we have enough notice. Please refer to the Cancellation Policy on our website.

By signing this form, you have read, understood and agreed our terms and conditions, privacy and authority to release information.

If after reading this form you are at all unclear about any of the information provided, please contact the psychologist prior to your appointment

Fees

Initial Appointment - $250
Initial Appointment Concession - $185
Multidisciplinary Reports - $750
All Therapy Consultations - $185
All Concession Consultations - $130

Health Fund and Medicare Rebates apply