Client Consent Form (For Minors)

Consent for a psychological service

As part of providing a psychological service to your child, the Childhood Cancer Association needs to collect and record relevant personal information, such as your child’s name, contact information, medical history and other relevant information as part of providing psychological services. 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 child’s personal information is managed, how you can access your child’s personal information, and how to lodge any concerns or complaints about this service must be provided to you by your health professional on request.

Disclosure of personal information

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 your child 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 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 child’s personal information to be disclosed to another professional or agency (e.g. your child’s GP) and disclosure of your child’s personal information to that third party is for a purpose which is directly related to the primary purpose for which your child’s personal information was collected; or
  5. disclosure is otherwise required or authorised by law.

Minors

For children aged under 18 years, information disclosed during a session will remain confidential, however there are important exceptions as listed above. Additionally, throughout the course of counselling, parents may receive limited general information regarding the sessions that are taking place. In the case that there is a high risk that the client will seriously harm themselves or others, I, as the parent/guardian will be immediately notified. Furthermore, you, as the parent/guardian may have the right to examine the treatment records or receive a summary of treatment. However, it is recommended that that you review these records in the presence of trained staff so the contents can be discussed, as these are professional records, and thus can be misinterpreted and/or upsetting to untrained readers.

Working with Children of Separated Parents

If you live in a separated, blended or non-traditional family here is some information about how we work with these families.

It is generally best for the child that all members of a parenting team are aware of and appropriately involved in their treatment. This means that your psychologist may want to work /communicate with all the key people in a child's life, wherever possible. Unless a court order specifically states otherwise, information about a child's appointments or treatment (except confidential information) will not be withheld from either parent, unless the psychologist believes it is NOT in the best interests of the child for the parent/s to be provided with this information. Please provide any parenting or court orders which are in place to your clinician.  

Given time and role constraints, like other medical practitioners we are not required to, and can't, seek permission to work with the child from the non-attending parent. Most of the time, we need to rely on the attending parent/caregivers to give feedback or information to the non-attending parent/caregiver. If the non-attending parent contacts us and seeks information, we will do our best to work with them.

Provision of a telehealth service

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. Childhood Cancer Association will be responsible for the cost of the call to you and the cost associated with the platform used to conduct telehealth services, will be the responsibility of the Childhood Cancer Association.

To access telehealth consultations your child will need access to a quiet, private space; and the appropriate device, i.e. smartphone, laptop, iPad, 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 COVIU, which is compliant with the Australian standards for online security and encryption.

Limitations of telehealth

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 child’s psychologist will consider and discuss with you the appropriateness of ongoing telehealth sessions.

Qualifications & Registration

Your child’s Psychologist is registered with the Psychology Board of Australia. Counselling will utilise a variety of evidence-based approaches including but not limited to Cognitive Behavioural Therapy, Acceptance and Commitment Therapy and Mindfulness-Based Cognitive Therapy. Please raise with your Psychologist/Counsellor any queries you have regarding any of these therapeutic approaches.

Fees and Cancellation Policy

There are no fees associated with receiving counselling services at the Childhood Cancer Association. It would be appreciated however if you could please give at least 24 hours’ notice if you need to reschedule or cancel your child’s appointment.

Communication with External Agencies

It is often helpful for your child’s Psychologist to speak with other key professionals (e.g. staff at the Women’s & Children’s Hospital) in order to plan appropriate treatment (e.g. appointments).  If you are willing for this to occur, please tick the box below. 

Consent 1 
Consent 2 

APS Charter for Clients of Psychologists

The APS Charter explains your child’s rights as a client of a psychologist. View APS Charter

Consent to Receive Psychological Services Including Telehealth Services

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

Emergency Contact 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 psychological services to be provided by the Childhood Cancer Association to my child.

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