New Client Intake & Consent Form

New Client Intake & Consent Form 2017-09-25T14:37:10+00:00

As part of providing a service to you, LifePsyche needs to collect and record personal information from you that is relevant to your situation, such as your name, contact information, medical history and other relevant information as part of providing services to you.

This collection of personal information will be a necessary part of the assessment and treatment that is conducted.

Your personal information is gathered as part of your assessment and treatment, is kept securely and, in the interests of your privacy, used only by your practitioner and the authorised personnel of the practice (as necessary). Your personal information is retained in order to document what happens during sessions, and enables the practitioner to provide a relevant and informed service to you. A more detailed description is provided in the practice’s “Privacy policy for management of personal information”, which is available on the LifePsyche website,

At any stage, you are entitled to access your personal information kept on file, subject to exceptions in the relevant legislation. Your practitioner may discuss different possible forms of access.

All personal information gathered by the health practitioner during the provision of the service provided to you will remain confidential except when:

  1. it is subpoenaed by a court; or
  2. failure to disclose the information would in the reasonable belief of the LifePsyche practitioner, place you 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, eg. a parent, employer or health provider; or
    3. disclose the information in another way; or
  4. you would reasonably expect your personal information to be disclosed to another professional or agency (e.g. your GP) and disclosure of your personal information to that third party is for a purpose which is directly related to the primary purpose for which your personal information was collected; or
  5. disclosure is otherwise required or authorised by law.

Your personal information is not disclosed to overseas recipients, unless you consent or such disclosure is otherwise required by law. Your personal information will not be used, sold, rented or disclosed for any other purpose.

The cost of a consultation (usually around “50” minutes) is $210.

The cost of a 30-minute session is $125.

Fees are payable at the end of the session by cash, cheque, eftpos or credit card. Credit cards incur an extra $2 fee. Bulk billing and reduced rates may be negotiated in cases of genuine hardship.

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If you need to cancel or postpone your appointment, you must give us 48 hours notice. If you provide between 24 and 48-hours notice, and we cannot fill the time allocated for your appointment, you will be charged 50% of the consultation fee. If you give less than 24-hours notice, and we cannot fill the time allocated for your appointment, you will be charged 100% of the consultation fee.
If this form won’t send please scroll up and check that all required fields have been filled in (any errors are marked in red). Alternatively you can request a pdf copy of this form from LifePsyche.

Please take a moment to read our Privacy Policy for more information.