{"Name":"Consent - General","Composition":{"Sections":[{"Label":"Consent","Fields":[{"Type":6,"Text":"Fees are based on a 50 min hour with 10 min note taking time and are charged proportionally for contact (in person, phone or email); report preparation and court waiting time. Fees are payable at the time of consultation. Cash, cheque and Credit Card payments are accepted, but EFTPOS (Cheque and Savings accounts) are not. Please note that unless there are exceptional circumstances the full fee is charged for sessions that are cancelled less than one business day (Monday to Friday 9:00am-5:00pm – 24hrs) prior to the scheduled appointment time.","Label":"Fees and cancellation","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":6,"Text":"Psychological Service:\nAs part of providing a psychological service we will need to collect and record personal information from you that is relevant to your current situation. This information will be a necessary part of the psychological assessment and treatment that is conducted. You may view and/or have a copy of the\nmaterial recorded in your file upon request, subject to the exemptions in National Policy Principle 6.\n\nConfidentiality\nAny issues raised during a session or phone consultation will remain strictly confidential. Without your written consent, subpoena or similar legal requirement to disclose, this information will not be discussed with any third party including partners, family members, GPs or other health professionals. Please note that all our staff are bound by a strict confidentiality code. \n\nPrivacy and Data Security\nLike most health service providers we collect information which is covered by the Privacy Act 1988. This information includes name and contact details as well as diagnostic and treatment information to enable us to provide psychological treatment. From time to time the practice conducts and\npublishes research however all data is depersonalised before doing so. This information is stored in PowerDiary's cloud database. We also use a service called FIT-Outcomes based in Ireland for session by session effectiveness tracking. The only personal data supplied to this service is your internal reference code, your first name and year of birth. In addition we use the Zoom meetings product that has been upgraded to the HIPAA compliant version which means that all data is encrypted at rest and across the web and in addition we enforce configurations to prevent accidental breaches of privacy such as disabling recording. Please let us know if you have any privacy concerns. Please let us know if you have any privacy concerns. \n\nPermission to Consult / Release Information\nAny issues that arise as part of assessment and treatment will remain strictly confidential. Without your written consent, this information will not be discussed with any third parties. We do however encourage a collaborative approach with referrers, GP’s and schools or other involved parties. Please take a moment to consider which if any of the following parties you are happy for us to contact to gain additional information, which of those you are happy for us to release information to and to what extent if any you would like that information to be restricted.","Label":"Privacy and confidentiality","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":3,"Text":null,"Label":"Please list any professionals with whom you consent to us collaborating with. Please note Medicare rebates are not available unless consent is given to collaborate with the referrer.","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":6,"Text":"Due to current legislation, your written consent to the above information is required. I would therefore ask that you sign the consent below prior to your first session. \nIf you have any further questions before you attend your first session, please do not hesitate to contact us.\nYours sincerely\nReception - Clinical Psychology","Label":"Consent","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":4,"Text":null,"Label":"I have read and understood the attached Information form. I agree to these conditions for the psychological services provided including the confidentiality and cancellation policies.","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":true,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":4,"Text":null,"Label":"I hereby give consent anonymous questionnaire results to contribute to the ongoing research and evaluation of programs","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":true,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":8,"Text":null,"Label":"I am happy to receive occasional communications including resources for common challenges and announcements relating to the services at <Business Name>. ","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"SubscribeToMarketingCommunication"},{"Type":0,"Text":null,"Label":"I would like appointment reminders sent: ","Options":[{"Label":null,"Value":"via SMS 3 days out","Selected":true},{"Label":null,"Value":"via Email 3 days out","Selected":false},{"Label":null,"Value":"Via SMS the day before","Selected":false},{"Label":null,"Value":"No reminders","Selected":false}],"CurrentValue":null,"IsMultiple":true,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":{"Required":{"Value":true}},"ProfileFieldType":"None"},{"Type":7,"Text":null,"Label":"Signature","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":{"Required":{"Value":true}},"ProfileFieldType":"None"}]},{"Label":"Payments and Rebates","Fields":[{"Type":6,"Text":"We use an online credit card payment system called Stripe which is integrated with PowerDiary rather than swipe terminals. This involves us entering your card number into PowerDiary and having it automatically authorised through the Internet using Stripe in a similar fashion to online shopping. Cash and cheques are also available, but if you do sign this form you are agreeing to us debiting the cost of consultations, late cancellations etc at the time payment falls due and posting a receipt if you are not present.\nThis agreement will remain in place until you complete treatment or ask us to remove your card details from our system. If you have any questions or concerns about this, please don’t hesitate to call or speak to reception on {BusinessPhone}. We will ask you to provide your credit card number in person at the time of the first consult, over the phone or via our line portal following your first consult. This consent is visible to all reception staff so we only ask for the last 4 digits of your card as a reference.\n\n","Label":"Credit Card Authority","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":2,"Text":null,"Label":"Name on Card","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":2,"Text":null,"Label":"Last 4 digits of your Credit Card Number","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":6,"Text":"If you have a GP Mental Health Care Plan that has been completed by your GP prior to your appointment and your session qualifies with the various requirements for rebates then either you can submit claims yourself, or if you share your Medicare information with us we can do it on your behalf so that at the time of your appointment or shortly after, we will \ntake the full fee and then put the claim through to Medicare and typically 24 hours later they will deposit the rebate into your bank account directly.","Label":"Medicare Rebates","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":1,"Text":null,"Label":"Medicare Rebates","Options":[{"Label":null,"Value":"I will not be claiming through Medicare","Selected":false},{"Label":null,"Value":"I would like claims processed on my behalf","Selected":false}],"CurrentValue":"I will submit claims to Medicare myself","IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":6,"Text":"Medicare requires the clients details on all claims","Label":"Attendee details","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":2,"Text":null,"Label":"Full name of person attending appointments ","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":2,"Text":null,"Label":"Medicare Card Number ","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":2,"Text":null,"Label":"Reference Number (Number next to attendees name on card) ","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":2,"Text":null,"Label":"Expiry Date ","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":6,"Text":"If someone other than the attendee such as a parent will be paying for appointments then we also require their details in order to process Medicare claims. Please skip to the consent if you are paying for your own sessions.","Label":"Payee's details","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":2,"Text":null,"Label":"Full name of person paying for sessions (If different from above)","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":2,"Text":null,"Label":"Payer's Date of Birth","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":2,"Text":null,"Label":"Phone Number","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":2,"Text":null,"Label":"Street Address","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":2,"Text":null,"Label":"Medicare Card Number (if different from above)","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":2,"Text":null,"Label":"Reference Number","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":2,"Text":null,"Label":"Expiry Date","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":null,"ProfileFieldType":"None"},{"Type":7,"Text":null,"Label":"I hereby agree to payments being taken and rebates being submitted as described above","Options":[],"CurrentValue":null,"IsMultiple":false,"Mode":null,"Checked":false,"ActiveDrawing":null,"SelectedDrawing":null,"Annotations":[],"Rules":{"Required":{"Value":true}},"ProfileFieldType":"None"}]}]},"FormType":"ClientEnteredAdmin","Files":[],"HasSupplierNotification":true,"NotificationEmails":"reception@ClinicalPsychology.com.au"}