Mind Mode Consent Form
A new consent form may be required:
• If you change clinicians, your new clinician will review and discuss consent with you during your initial consultation.
• If there are changes to our policies or to your treatment plan, consent will be revisited to ensure you remain fully informed about the factors influencing your care. Consent may also be reviewed at the beginning of a new treatment cycle where clinically appropriate.
• Consent will be renewed every 12 months following your previous agreement to ensure compliance with required standards and best practice guidelines.
• You may discuss your consent at any time with your clinician and can request a new consent form through your clinician or the Mind Mode administration team if you wish to refresh your understanding and reconfirm your agreement.
If you have any questions or would like to discuss any of the information provided, please do not hesitate to contact us or speak with your clinician.
A 'combined consent form'
This consent form covers consent for both Mind Mode and your clinician who may trade as an individual entity. Please be aware that most clinicians working under the Mind Mode brand are sole traders or individual entities running their own business.
Mind Mode acts as a facilitative, managerial, and administrative service for these individual entities,which is why many of the forms and resources provided to you will reference Mind Mode but also be referring to your clinician’s individual business entity. This is a common way for Allied Health Private practices to operate.
Please be aware that any forms or agreements you are asked to sign, including this one, act as a combined document for your convenience however, your clinician and the individual entity they run are ultimately responsible for your care and the maintenance of your information.
Charter for clients of Mind Mode
The rights of the client:
All psychologists are legally required to be registered in Australia with the Psychology Board of Australia and AHPRA. Mind Mode also requires our counsellors to be registered with PACFA, and Dietitians be registered through Dietitians Australia which means your clinician is registered with a body that maintains safeguards and checks to ensures that your clinician is properly trained and ensures that you receive high quality, ethical service.
• As a client of a Mind Mode clinician, you have a right to expect that: You will be treated with respect at all times
• Your cultural background and language tradition will be respected You will be given a clear explanation of the services you will receive
• You will be asked to give your consent for any service provided by your clinician prior to the service commencing and as it progresses
• You will receive an explanation about the confidentiality of the service and the exceptional situations where your confidentiality may no t be protected
• You will receive a clear statement about fees for your clinician’s services You will receive skilled and professional services from your clinician There will be clear goals that you and your clinician are working toward You can ask any questions about the service you are receiving
• Your clinician will be willing to receive feedback and requests for changes in approaches and methods.
NOTE: If you have any concerns about the above matters, please discuss them first with your clinician. If you have concerns about the conduct of your clinician, please contact Mind Mode Management through the email practicemanager@mindmode.com.au and your concerns will be addressed as a priority. You may also call any of the above-mentioned bodies depending on the registration of your clinician.
Responsibilities of the client:
Psychology, counselling, and dietetics are human services that require the provision of a safe space. We acknowledge that with each right we have we also have responsibilities, and these responsibilities are in place to ensure the safety of yourself, our staff, other client’s, and others that you may encounter during your work with us.
As a client of a Mind Mode clinician, you will be expected to uphold the following responsibilities:
• Respect other people’s rights to a safe, secure, and comfortable environment.
• Treat other clients, staff, individuals, and volunteers with fairness, honesty, and respect. Respect the Mind Mode space and never enter an office without your clinician.
• Respect other people’s rights to privacy and confidentiality, this extends beyond the waiting room.
• Understand your own rights to confidentiality and the restrictions/exceptions outlined in your confidentiality form
If you have queries regarding this, it is your responsibility to seek clarification and to act in a respectful manner if your practitioner is required to enact their legal obligations.
• Actively participate in your treatment, discussing and agreeing to a treatment plan with your psychologist/counsellor/clinician and communicating to them when you feel that something is not working, or you would like to request a change.
• Attend sessions to the best of your ability and on time in a ‘fit state’, without being inhibited by substances or alcohol.
• Be aware of your financial obligations, including being aware of the cancellation policy. Mind Mode is aware that financial stress can imp act on your well-being and attendance to treatment. Our fees are set below the Standard Fee Schedule of the Australian Psychological Society in an effort to remain available to clients with financial concerns. Further exceptions can be made if you are living in a refuge, or are with Domestic Violence services, please speak to your psychologist/counsellor/clinician if this is the case.
• Not record sessions in any form without the permission of the psychologist/counsellor/clinician. Utilise material and information provided for its intended purposes only.
This includes reports and support letters, which should be provided only to the intended recipient in the agreed upon context, as well as any copyright material produced by your practitioner.
Consent and Confidentiality
Records, Consent, Confidentiality, Release of Information Your Information, Consent, and Confidentia
PSYCHOLOGICAL, COUNSELLING, AND DIETETIC SERVICES
As part of providing clinical services to you, your clinician needs to collect and record personal information from you that is relevant to your sit uation, such as your name, contact information, medical history and other relevant information. This collection of personal information will be a necessary part of the assessment and treatment that is conducted.
Your clinician receives supervision as a part of best practice and a requirement for their ongoing registration. Clinicians utilise supervision to ensure they’re providing best treatment for your needs. When discussing client treatment in supervision, clinicians are required to discuss in a de-identified way that protects your confidentiality. If you have specific things you do not want your clinician to disclose or discuss in supervision, please discuss this in your sessions.
PURPOSE OF COLLECTING AND HOLDING INFORMATION
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 clinician and the authorised personnel of the practice (e.g. administration staff). Your personal information is retained in order to document what happens during sessions and enables the clinician to provide a relevant and informed clinical service to you. When referred to treatment under Medicare it is part of legislation the reports of progress be provided to the treating GP. If you have not been referred by your G P, it is still recommended that you provide permission to contact and share information with them to ensure continuity of care and holistic treatment.
ACCESS TO PERSONAL INFORMATION
Clinicians at Mind Mode own their own notes and clinical information under their individual entities. At any stage you are entitled to access your personal information, subject to exceptions in the relevant legislation and clinical safety. Your clinician may discuss with you the different forms of access to this information.
DISCLOSURE OF PERSONAL INFORMATION
All personal information collected during the provision of psychological services is treated as confidential. Your information will only be disclosed in the following circumstances:
• If required by law, including if the information is subpoenaed by a court.
• If there is a serious risk of harm, where your clinician reasonably believes that failing to disclose the information would place you or another person at serious risk to life, health, or safety.
• With your consent, including to:
- Provide a written report to another professional or agency (such as a GP, lawyer, or insurer);
- Discuss relevant information with another person involved in your care (forexample, a parent, employer, or health provider);
- Disclose specific information for another agreed purpose, based on explicit informed consent.
• As part of your care, your personal information may be shared with another professional or service (such as your GP). This would only occur where it is directly related to your care and something you would reasonably expect.
• Where disclosure is otherwise authorised or required by law.
Your personal information is not disclosed to overseas recipients unless you provide consent or such disclosure is required by law. Your information will not be used, sold, rented, or disclosed for any other purpose.
SUPERVISION
- As part of maintaining ethical practice and registration with our governing bodies, clinicians are required to attend supervision sessions with senior clinicians, peers, or board approved supervisors. These supervision sessions are to ensure high-quality client care, support the professional development of the supervisee, and uphold ethical standards by providing a structured space for reflection, skill development, and guidan ce, especially for trainees, helping them gain competence, manage challenging cases, prevent burnout, and maintain self-awareness. By signing this form, you are indicating that you agree to your clinician discussing your treatment in supervision through de-identified means.If you have queries regarding supervision and how your information will be delivered or used, please discuss this directly with your clinician.
FILE RETENTION AND DISPOSAL
Your clinician is required to keep confidential records of your sessions. These records are stored securely and used only for your care or where required by law. Client files are generally retained for a minimum of 7 years after your last contact, or (for children) until at least age 25. In some circumstances—such as for Indigenous clients, victims of crime, or where otherwise required by law—files may be kept for longer periods. After the required retention period, your records will be confidentially destroyed (e.g., paper records securely shredded, electronic files permanently deleted).You may request access to the information held in your file at any time, subject to legal and professional guidelines. Your clinician may discuss the different forms of access.
SOFTWARE
RISKS AND BENEFITS OF THERAPY
Mind Mode acknowledges the need for some clients to attend sessions outside of normal business hours, and a number of clinicians have chosen to provide these sessions for the convenience of those who need them. Out of hours sessions will attract a 10% surcharge to cover the costs of running these sessions outside of normal business hours, including the time taken after the session to complete tasks created by the session. Mind Mode has a number of ways you can make payment. Unfortunately, due to the fees charged by the eftpos providers, a surcharge will be charged on credit and debit card payments. In response to these fees Mind Mode also provides payment methods that do not charge a fee. The preferred method of payment is via PayID (pay@mindmode.com.au), we can also provide you with bank details for a transfer, or we can also accept cash.
Mind Mode Policy
COMMUNICATION AND SOCIAL MEDIA POLICY
In order to communicate with you we use email, text and phone calls. From time to time our clinicians may contact you via email to provide re sources, updates or other relevant information. Our clinicians will also occasionally text you through Zanda (previously known as Power Diary) to confirm appointments or provide updates. Please be aware that all communications done through the Zanda program, including all texts, a reviewed by the Mind Mode admin team and that these communications are attached to your clinical file. If you need to change an appointment or discuss something with your clinician, the best way to contact us is through our administration team. Please do not contact Mind Mode via Facebook, Instagram, or any other social media account as they are not regularly monitored and as they are not designed for this purpose, you may not be answered promptly, and you may be compromising your confidentiality. If you wish to communicate directly with your clinician without the admin team involvement, you will need to first discuss this with your clinician as to their preferred secure method.
TELEHEALTH POLICY
Provision of a Telehealth service:
Where appropriate the service may be provided by telephone or videoconferencing. You are responsible for the costs associated with setting up the technology needed so you can access Telehealth services. Mind Mode and your practitioner will be responsible for the cost of the call to you and the cost associated with the platform used to conduct Telehealth services. To access Telehealth consultations, you will need access to a quiet, private space, an appropriate device, i.e. smartphone, laptop, iPad, computer, with a camera, microphone and speakers, and a reliable broadband internet connection. If others are within the same room or within listening distance, you are required to disclose this to the clinician. For safety reasons we cannot conduct Telehealth sessions whilst you are operating a vehicle or machinery. If your clinician identifies any safety or ethical concerns with the environment, you are attending your session from alternatives may be discussed or the appointment may be rescheduled to another time. By signing this consent, you are stating that you understand and agree not to record, either visual or audio information, whilst conducting a Telehealth session, unless discussed and agreed upon with your clinician. Your clinician understands and agrees to the same. The privacy of any form of communication via the internet is potentially vulnerable and limited by the security of the technology used. To support the security of your personal information this practice uses Zanda (previously known as Power Diary) in conjunction with Doxyme, or Zoom, for Telehealth sessions, which are all compliant with the Australian standards for online security and encryption.
Limitations of Telehealth:
OUT OF OFFICE SESSIONS
Based on client needs there may be some clinicians that offer Out of Office as a part of treatment.
This will be collaboratively discussed between yourself and your clinician to ensure that it is both clinically appropriate and meets the needs of your treatment. In Out of Office Sessions the clinician will complete a risk assessment to assess suitability for this service, and we ask all clients to be mindful of their environment and any hazards or risks that may be present. The Risk Assessments conducted can be requested as needed.
We ask all clients to be aware and agree to the following;
• You understand the limitations of being able to control the environment outside of the office and you accept the possible limitations to confidentiality and privacy that being outside, in public, or in an alternative venue may create.
• Inform your clinician if there is anything that would impact conducting Out of Office Sessions i.e. risk to self or others, physical limitations or health implications for walking sessions etc.
• Accept the risk of injury as your own and agree that Mind Mode cannot be held liable for accidents or injuries that occur due to being out of office. Further, during home visits, you accept responsibility and liability for the risk and any injuries that may impact your clinician.
• Be open in your communication if circumstances change with yourself or your environment.
• Respect the privacy and confidentiality of your sessions and attend your sessions privately (unless previously discussed with your clinician). Discuss any aspects of your environment that may impact yourself or the practitioner i.e. the presence of pets due to allergy or comfort.
• Understand that Out of Office sessions will be reviewed in an ongoing basis and there may be a requirement to change delivery method of the session if an alternative is deemed more suitable.
Reasons why a clinician may advise against Out of Office sessions are;
• If there is not enough privacy in the environment so confidentiality would be compromised for yourself or the clinician. If the environment is considered to be a risk or unsafe for either the client or clinician.
• If there are risks of harm to self or others that would be more appropriate for an in office session or alternative service to address.
Limitations of Out of Office Sessions:
An Out of Office Session may be subject to limitations such as traffic impacts/delays, environmental risks, or weather concerns which may affect the ability to conduct the session appropriately. In addition, there may be some services for which Out of Office sessions are not appropriate or effective. Your clinician will consider and discuss with you the appropriateness of ongoing Out of Office sessions.
If issues interfere with the session to the point that we cannot continue, your clinician will call you on the phone to discuss your options, which may include continuing the session by phone, Telehealth or in office.
Psychological Assessments
Assessments:
Based on client needs there may be some clinicians that offer formal assessments as a part of treatment. If you have sought out treatment through Mind Mode specifically for a formal assessment, your welcome email would have included/will include an Assessment Booklet which provides a basic structure of the sessions and fee scheduling. Formal Testing and Assessment will be a collaborative process by which your clinician will discuss with you the structure, benefits and consequences of any assessment you undertake.
Software used for assessments:
The clinician utilises various software programs to access to the appropriate testing and assessment information and tools. Each clinician conducting testing and assessment has access to these shared resources. Each clinician using any shared practice software has agreed and signed documentation indicating they will uphold the confidentiality principles by not accessing any information regarding clients not allocated to their case load. Once your assessment information and process are completed, your information will be securely stored in your client file and removed from t he assessment software database.
Fees, Cancellation & Communication
Cancellation Policy:
WE REQUIRE 48 HOURS NOTICE FOR ANY APPOINTMENT CHANGES, CANCELLATIONS AND RE-BOOKINGS.
Our cancellation policy ensures that all clients have a chance to see their clinician at their earliest convenience. We understand that circumstances may arise that require you to cancel your appointment, but providing adequate notice allows other clients an opportunity to fill your spot. If you need to cancel or postpone your appointment, please provide *a minimum of 48 hours notice*. Failure to do so will result in a cancellation fee of 50% of the scheduled session fee. If less than 24 hours notice is given, or you fail to attend a schedule appointment, you will incur the full cost of the scheduled session. In out of office times our appointment reminder text system and email address can still receive communication to indicate an appointment is cancelled. This policy refers to all clients. Where third parties responsible for our fees do not pay for late cancellations or failure to attend a scheduled appointment, you may be required to personally pay. Reminder texts and emails are set to be sent prior to the appointment for your convenience however, it is your responsibility to ensure you manage your own appointments in the appropriate time frame.