Online Referral Form

Please note we are not an emergency service; our phones and emails are not constantly monitored. In an emergency situation please contact 000 for police/ambulance.
• Police or Ambulance - 000
• Mental Health - 13 14 65 Lifeline - 13 11 14 or www.lifeline.org.au
• Kids Helpline (5-25 years) - 1800 55 1800 or www.kidshelpline.com.au • Suicide call back service - 1300 659 467 or www.suicidecallbackservice.org.au

No service can be provided without informed signed consent.

Please provide your details in the section below if you are completing this form on behalf of client.

Your informed consent will be obtained each year and/or before any assessment, treatment or procedure is initiated. You may withdraw from treatment at any time without prejudice. Reasonably foreseeable risks, adverse effects, and possible disadvantages of the assessment, treatment or procedure will also be detailed in advance.

I agree that personal information specific to my health, diagnosis, assessment, disability and/or therapy and intervention requirements may be shared and gathered with the following agencies and persons (if required):

Limitations to confidentiality
All personal information gathered by the ECM Allied Health Professionals and administration staff during the provision of assessment and therapeutic services and/ support will remain confidential except when:

1. subpoenaed by a court; or
2. Suspected or reported risk of harm to self or others (i.e. suicidal or self-harm ideation/plan/intent; homicidal ideation/plan/intent); or
3. Criminal act requiring reporting to the Policing Services;
4. or Current alleged or actual observed abuse, harm or neglect to a client requiring reporting to authorising bodies as per NDIS Practice Standards (this could include, for example, Child Safety/ Protection bodies across States and Territories or the NDIS Quality and Safeguarding Commission); or
5. Your prior approval has been obtained to:
   • provide a written report to another professional or agency. e.g. GP, school, or a lawyer; or
   • discuss the material with another person, e.g. a parent, employer, or health provider; or • disclose the information in another way; or • When consulting with colleagues, or • In the course of confidential clinical supervision, your clinician may be required to conceal your identity and any associated parties involved; and to preserve your privacy at the utmost professional manner in accordance with the NDIS Quality and Safeguarding Commission Practice Standards and Codes of Ethics of professional registration bodies. If there is a risk to you, or to someone we work with, ECM may need to share information with the relevant third parties. If we need to provide your information as a legal requirement, we will let you know this has occurred.

Privacy & Consent Statement

If you need to withdraw your consent, you can do so at any time by calling us or writing to us. We are required to review your consent to share information every year at a minimum, to ensure it is up to date, relevant and we have currency of information.

Exchange of Information

I hereby acknowledge that ECM has advised me/the client of the following:

• Why ECM collects personal information.
• Why ECM collects pertinent history and past reports.
• What happens to personal information?
• How it is used and how it is stored
• Client rights to access personal information.
• Client rights to withdraw consent at any time.

To provide a quality therapeutic service and support to our clients, I am/ the client is aware and understand that ECM may receive and disclose ‘Personal Information’ as necessary and required, and may need to inform others of your diagnosis/disability, pertinent history, potential risk, assessment results, behavioural concerns, interventions, client progress, change in circumstances, provision of therapy, support services required, NDIS application and/or applications etc with other government agencies (Centrelink).

Allied Health Assistant/Counsellor/Behavioural Therapist

ECM Allied Health Professionals may utilize other Allied Health Professionals including: Allied Health Assistants, Counsellors, Behavioural Therapist in support of therapy and targeted interventions. Allied health assistants are qualified to implement a range of therapy and programs under the supervsion by qualified Allied Health Professionals (Psychologist, Speech Pathologist, Occupational Therapist).

Fees

Fees (initial consultations, assessments, telehealth, therapy, groups, reports, clinical stakeholders meetings, and resources) are payable at the time the service is provided. An initial consultation appointment cannot be organized without a $80.00 deposit (non-refundable if client does not attend). Fees will vary depending on Allied Health Professionals discipline hourly rates ranging from $185 to $270 and length of service. Report fees will depend on Allied Health Professionals discipline hourly rates and will be governed by a time frame from 1-4 hours (Summary and Progress Reports) to 10-20 hours (Psychological, Speech, Multi-disciplinary Functional Reports and Behavioural Management Plans), payable prior to report distribution. Supports for participants under the National Disability Insurance Scheme (NDIS) will be subjected NDIS Pricing Arrangements and Price Limits charged at the hourly rate specified for each discipline and for each service provided (updated yearly) this may include assessments, progress reports, clinical stakeholders meetings, resources, and phone consultations. Please visit https://www.ecmonhudson.com for information regarding Allied Health Professional Services and Fees. If booking under Medicare or Private, there are out of pocket fees for appointments, even with a Mental Health Care Plan from your GP. No Medicare rebate is available for sessions with provisionally registered Psychologists: as such, ECM offers these sessions at a reduced rate.

Cancellation Policy:

ECM has put in place a cancellation policy to ensure that enough time is provided to offer the appointment time to another client. If less notice is provided, other clients may miss out on obtaining the services they require. Amendments to appointments must be made via phone (02 4969 8060) or via email (info@ecmonhudson.com) and must be made within 2 business days of the appointment scheduled. A 100% consultation /service fee will be charged if ECM is not notified within 2 business days. This applies to ALL participants (NDIS, Medicare, Private and those clients who are supported by other organization) and applies to ALL services provided by ECM. A Debt Collection service may be used to collect outstanding debts (if required).

Privacy and Confidentiality

All personal information, assessment results, and documentation collected by ECM Allied Health Professionals is considered ‘confidential’. Commonwealth Privacy Act 1998. All documentation is electronically stored by Zanda Management system -ISO 27001 certification. Documents can only be accessed by ECM clinicians and/ or administration team via Authentication (MFA).

Limitations to confidentiality

All personal information gathered by the therapist during the provision of therapeutic services will remain confidential except when:

1.  It is subpoenaed by a court; or
2. Suspected or reported risk of harm to self or others (i.e. suicidal or self-harm ideation/plan/intent; homicidal ideation/plan/intent); or
3. Criminal act requiring reporting to the Policing Services; or
4. Current alleged or actual observed abuse, harm or neglect to a client requiring reporting to authorising bodies as per NDIS Practice Standards (this could include, for example, Child Safety/ Protection bodies across States and Territories or the NDIS Quality and Safeguarding Commission); or
5. Your prior approval has been obtained to: a. provide a written report to another professional or agency. e.g. GP, school or a lawyer; or b. discuss the material with another person, e.g. a parent, employer or health provider; or c. disclose the information in another way.

Please note ECM are mandatory reporters and obligated to report ALL suspicions and allegations of abuse. GP’s require review letters throughout the year that often include a summary of sessions. For those on the NDIS, it is a requirement to provide (at a minimum) a progress report at each review stage. Medicare and NDIS require review reports throughout the year that often include a summary of assessments and therapy.

• Length of Service -Allied Health Professional consultations/ assessments 30-180 minutes depending on the service to be provided -ranging from phone consultation, telehealth, individual therapy, resource management, individual therapy to assessments and home/school visits.
• Initial consultations, assessments, and therapy: $185.00- $850.00 (determined by discipline hourly rate or assessment administered) payable at the end of each session.
• Group Program: specific to program and charged weekly as per allied health professional clinical rate (available on request) 
• Multidisciplinary report $1500.00 -$2,500
• Allied Health Professional diagnostic, assessment and progress summary reports (determined by discipline hourly rate and ranging from 1-15 hours) payable prior to report distribution of the report.
• Clinical Stakeholder Meeting: $120.00- $270.00 per hour, (determined by discipline hourly rate).
• National Disability Insurance Scheme: charges as per NDIS guidelines and charged on an hourly rate • A fee schedule or quote for services can be provided at your request (approximation only).

ECM Policies and Procedures

I hereby confirm that I am aware that ECM has a range of policies and procedures available on request and/or available on their website www:ecmonhudson.com. ECM strives to ensure that we are compliant and meet all National Legislations, Professionals Code of Conduct, and NDIS Practice Standards. ECM is an approved registered and audited NDIS provider since 2013.

• Zero Tolerance Policy
• Disputes, Feedback and Complaints Policy
• Privacy Policy
• Confidentiality Policy
• Risk Management Policy
• Social Media Policy
• Workplace Surveillance Policy
• Gender Equality, Inclusion and Diversity Policy
• Artificial Intelligence (AI) Policy

As a registered National Disability Insurance Scheme (NDIS) provider, ECM must undergo regular reviews of our services and supports. As an NDIS participant you may be contacted by the Commission to provide input into the audit. However, you can also choose to opt-out of the audit process if you wish. If you would like to opt-out, please indicate below.

As the client/ carer/ legal representative, my signature below indicates that I have a sound understanding of all the rules and responsibilities of both the client and the clinician, in addition to understanding professional fees and ECM policies accessible in clinic and on website. My signature constitutes my agreement and compliance with this document. I, as well as my clinician, will abide by the stipulations listed herein.

If, after reading this form you are unclear about any of the information provided, please contact Educational Case Management on 0249698060 and ask to speak with Management or a Clinician. Please Note: An Easy Read version is available on request. Please sign here to give your consent as indicated in this form.