Consent Form

This Consent Form is entered into between Dr Metaxia Toumbelekis ABN 19 190 332 733 (referred to as we, our and us) and you, the person signing up to receive our services. It outlines the terms and conditions on which we provide the services to you, and how we treat your personal and confidential information. Please read this form carefully, and let us know if you have any questions.

Emergencies

Please note that we are not a crisis service and are not appropriately equipped to respond in the event of an emergency. Email and phone messages are not attended to every day. If you are in need of urgent psychological or medical assistance please contact 000. If you require emotional support between appointments you can call Lifeline anytime on 13 11 14. We have also listed a number of helpful contacts on our website.

COVID-19

By accepting this Consent Form, you acknowledge that there are risks associated with attending your appointment at our practice, rather than via a telehealth consultation, and to the extent permitted by law you release us from any responsibility or legal liability associated with you contracting COVID-19 or any infectious illness after attending our practice.

By attending an appointment at our practice, you confirm that you (or anyone you live with or have been in contact with):

• do not have any flu-like symptoms;
• have not been overseas in the past 14 days;
• have not been instructed to self-isolate; or
• have not tested positive to COVID-19 in the past 30 days, or are currently awaiting COVID-19 test results, and

if any of the above apply you will contact us so we can move your appointment online.

If you attend your appointment at our practice, you must comply with the Government regulations which are in effect at the time you attend your appointment, which may include practising physical distancing while waiting for, during and after your appointment, wearing a face mask and sanitising your hands frequently.

You agree to notify us as soon as possible if you test positive for COVID-19 and have attended our practice in the past 30 days.

Fees

We pride ourselves on providing you with high quality, collaborative and personalised care. We are a private billing clinic and all consultations have an out of pocket cost, with the exception of where this has been explicitly discussed.

Appointment fees vary depending on the type and length of consultations. Please see our website for a list of our consultation fees. Fees are periodically reviewed and changes to the fee structure may result in an increase in the fees associated with your consultations.

Payment Terms

You will need to provide your credit card details to secure an appointment. Your secure payment will be made through our client management system Halaxy (please see there website for further details). The full amount or remaining balance will be debited from your nominated credit card on the day of your appointment.

If for any reason you cannot make your appointment and 48 hours’ notice is not given, 50% of this fee will be charged as a cancellation fee. For bulk billed appointments you will be charged 50% of the bulk bill amount.

Cancellation Policy

We acknowledge that unexpected life events may interfere with your ability to attend your appointment. Unfortunately, last minute cancellations, re-schedules or nonattendance may result in another client missing an opportunity for timely treatment. We have developed a cancellation policy with this in mind. If you are unable to attend your appointment, please contact us as soon as possible so we can endeavour to fill your session.

We appreciate your help and understanding. Cancellations made more than 48 hours in advance will not incur any fee. Non-attendance or cancellation at short notice (less than 48 hours) will incur a cancellation fee equal to 50% of the consultation fee. Your nominated credit card or account will be charged accordingly. Unfortunately, cancellation fees are not eligible for a Medicare rebate.

No cancellation fee is payable if you notify us that you cannot attend your appointment at our practice due to COVID-19-related concerns, and instead attend your appointment via a telehealth consultation.

Timeliness and Attendance Policy

To ensure that we respect the time of all our clients, if you arrive late for your scheduled appointment, please note that we will still need to conclude at the originally planned time. This helps us stay on schedule for others who are also counting on us. We appreciate your understanding and cooperation.

If you are unable to attend your appointment and do not inform us in advance, the full session fee will be applied. Additionally, please be aware that missed appointments without prior notice will not qualify for a Medicare rebate. We value your time and hope to provide the best service possible, so timely communication is greatly appreciated.

Workcover and Third Party funded sessions

We do not invoice third parties directly. If you are funded by third party organisations, it is your responsibility to pay for your session on the day of your appointment. Additional fees will be charged to you for any reports, surveys, questionnaires or other information required by your third-party provider (including printing and postage). These fees will be invoiced and paid in advance.

Reports

Reports and Letters requested for your school, TAFE, University, or similar organisations, will incur additional fees. These fees will be charged to your nominated credit card.

Collecting and Holding Personal and Confidential Information

As part of providing our services to you, we will need to collect and record personal information relevant to your current, situation, psychological/ health assessment, and treatment. All personal information is collected in accordance with our Collection Notice below, and further detailed in our Privacy Policy. We treat your personal information confidentially, in accordance with relevant privacy laws. In some circumstances, there are some exceptions to confidentiality, as outlined below.

Collection Notice

We collect personal information about you in order to contact and communicate with you, to respond to your enquiries, provide our services to you, which will be delivered in the form of psychological therapy/ group therapy/ workshops/ clinical supervision, and for other purposes set out in our Privacy Policy. We may also collect personal information, including your name and phone number, and the date and time of your appointment, where required by Government directions in relation to COVID-19.

We may disclose the personal information we collect to third parties in accordance with the following:

• if requested by State health authorities, including the Department of Health and Human Services, we may disclose your name, phone number and the date and time of your appointment (and any other required information), for contact tracing purposes and as otherwise required by Government directions or law;
• if we receive information that you have tested positive for COVID-19 and are not following the applicable Government requirements, we may provide this information to health authorities in accordance with the recommendation of our peak bodies and other regulatory authorities;
• if you have been referred to us by another health professional (e.g., General Practitioner), we may provide them with information about your treatment. If you do not want a referrer to be provided with information about your treatment, please advise your treating practitioner from the outset (please note that this may render you ineligible to receive Medicare rebates as this is a requirement of Medicare funding);
• in instances where mental health or other health professionals may be involved in your assessment or treatment external to our practice (e.g., psychiatrist) they may contact your practitioner at our practice. To assist them in your care, your practitioner may disclose information regarding your treatment. If you do not want an external mental health or health professional to be provided with information about your treatment, please discuss with your treating practitioner from the outset;
• in line with principles of best practice and registration, your practitioner engages in professional development including supervision which involves them discussing clients and their associated treatment with other health practitioners. If you would like more information about what your practitioner may discuss, please discuss this with your treating practitioner;

We may also disclose your personal information to:

• your private health care insurance provider (to the extent we are required to do so);
• our third party service providers who help us deliver our services to you (including our practice management cloud based software Halaxy, digital platforms, marketing providers, payment processors and our professional advisors); and
• and as further set out in our Privacy Policy.

In certain circumstances, we may disclose your personal information to third parties located, or who store data, outside Australia and where we do so we will do so in accordance with our Privacy Policy and applicable law.

All personal information collected and stored by us will remain confidential except where:

1. failure to disclose the information would place you (the client), or another person at serious and imminent risk; OR
2. it is subpoenaed by a court; OR
3. your prior approval has been obtained to:
   1. provide a written report to another professional or agency, or
   1. discuss the material with another person e.g., family member or employer; OR
4. if disclosure is otherwise required or authorised by law.

If you do not provide us with the relevant information, we may not be able to provide our services to you.

Our Privacy Policy located on our website contains further information about: (i) how we store and use your personal information; (ii) how you can access and seek correction of your personal information; (iii) how you can make a privacy-related complaint; and (iv) our complaint handling process.

By providing personal information to us, you consent to us collecting, holding, using and disclosing your personal information in accordance with our Privacy Policy and this Collection Notice.

Assessment and Report

By commencing treatment your practitioner is not consenting to conduct a formal assessment, write a report, or act as an advocate. We do NOT provide court/ forensic reports or offer professional opinions. If you require this type of service please talk to us for other referral options.

Telehealth/Online Sessions

Please ensure that when you engage in telehealth/online treatment you are situated in a private environment where other people cannot hear the content of your session. Due to the nature of online sessions and the medium used we cannot guarantee the security of information throughout the transmission. By signing this form, you acknowledge and agree to the limitations of confidentiality and information security of an online session.

Governing Law

This Consent Form is governed by the laws of New South Wales, Australia. Each party irrevocably and unconditionally submits to the exclusive jurisdiction of the courts operating in New South Wales, Australia and any courts entitled to hear appeals from those courts and waives any right to object to proceedings being brought in those courts.

CONSENT

By accepting this Consent Form, you:

• agree that you understand the nature of the service you will be receiving, your rights and responsibilities in relation to this service and the limits regarding your personal information and confidentiality and the terms and conditions of our service;
• consent to your personal information being collected, used and disclosed in accordance with the above; and
• agree that you are willing for your de-identified information to be used for the purposes of research and evaluation conducted by us and our associated partners.