Counselling - Minor Consent Form

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Yes, I give consent for my child’s Psychologist 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 child’s Psychologist 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 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

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 to my child.

Child's First Name

Child's Last Name

Parent / Guardian Full Name

Parent / Guardian Signature

Date