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(Minor) In-Person Consent Forms & Privacy Statements

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As part of providing a psychological service to your child, I (Bronwyn Russo - Clinical Psychologist) will need to collect and record personal information that is relevant to your child’s current situation. This information will be a necessary part of the psychological assessment that is conducted. Information is required to be accurate, complete and as up to date as possible.

Access

You may access the material recorded in your child’s file upon request. Copies of reports are available although charges apply.

Confidentiality

All personal information gathered during the provision of psychological service will remain confidential and secure except when:

  1. It is subpoenaed by a court; or
  2. Failure to disclose the information would place your child or another person at risk; or
  3. Your prior approval has been obtained to:
  4. provide a written report to another professional or agency e.g. a GP or another professional; or
  5. discuss the material with another person e.g. a parent

Generally files are kept for a minimum of five years then destroyed.

Cancellation

If you need to cancel or postpone the appointment, please give at least 24 hours notice, otherwise you will be charged in full for the missed session.

Definition of Services:

I , (Print Name In Block Capitals)

have read and understood the above Consent Form.

I agree to these conditions for the psychological service and I give consent for my child,

(Print Name In Block Capitals)

to be seen by Clinical Psychologist, Bronwyn Russo.

Client's Signature:
Date / Time:

Please Note: If, after reading this page you are unsure of what is written, please feel free to discuss it with me.

 

Bronwyn Russo

Clinical Psychologist