Counselling - Adult Consent Form

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Yes, I give my consent for my Psychologist/Counsellor to provide information to my family’s Social Worker or Medical team at the Women’s & Children’s Hospital (WCH).

Yes, I give my consent for my Psychologist/Counsellor to discuss information relating to the psychological support I am receiving with a Psychologist from the Department of Psychological Medicine at the Women’s & Children’s Hospital (WCH).

Other (Please Specify)

APS Charter for Clients of Psychologists

The APS Charter explains your 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 welfare and is unable to contact me permission is provided for the psychologist to contact the following person:

Emergency Contact Person

First Name

Last Name

Phone

Relationship to Client

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.

Full Name

Signature

Date