New client intake

Consent and Confidentiality

This form is to be filled out prior to your first appointment. Please fill it out as accurately as possible, as this will help our staff get your appointment confirmed easily, and save you time when you arrive at the clinic. If you’re unsure about anything it’s alright to discuss it with reception staff or your Psychologist before or during the session. Please take a couple of minutes to read the clinic conditions.

Clinic policy and confidentiality

Psychological service

As part of providing a psychological service to you, 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 do not have to give all your personal information, but if you don’t, this may mean the psychological service may not be able to be provided to you.

Privacy policy

The allied health service provided is bound by the legal requirements of the National Privacy Principles from the Privacy Amendment (Private Sector) Act 2000.

Information collection

Your personal information is gathered as part of your assessment and treatment. Your information is retained in order to document what happens during sessions, and enables the psychologist to provide a relevant and informed psychological
service to you.

Access to your infomation

At any stage clients may request to see the information about them kept on file. The Maple Street psychologist may discuss the contents with the job seeker and/or provide a copy of the file (note: administration costs will be incurred). All requests by
clients for access to information held about them should be lodged via the Maple Street Psychology Client Request for Information form.

Exchange of client infomation

There may be times where as part of the assessment and therapy process it may be helpful for your psychologist to liaise with other people or agencies that are relevant to your therapy goals (e.g. your GP, specialist, parent, WorkCover, etc).

Please note, that if you intend to claim rebates from Medicare or another organisation (such as WorkCover), and then your psychologist must provide summary reports to external agencies regarding your treatment progress. Under the Medicare scheme, these reports will normally be sent to your GP or psychiatrist.

In addition, administration staff may be involved in the handling of client information at times (i.e. when scheduling appointments, taking client information forms and measures). One member of our administration team members is located in the Philippines and at times may manage the uploading of documents to client files.

Limitations to confidentiality

All personal information gathered by the Act mindful psychology during the provision of professional services will remain confidential in line with Privacy laws expect when;

1. The information is subpoenaed by a court or,
2. Failure to disclose the information would place you or someone else at risk,
3. Your prior approval has been obtained to seek, exchange or obtain information from relevant parties (e.g. your GP, Centrelink, insurance companies, WorkCover, family members).

Cancellation Policy

If you do not attend your appointment or provide 24hr notice that you need to reschedule your appointment you will be charged the FULL FEE for the session, which is $140.

This fee will be charged to your credit or debit card.

If you do not attend an appointment, if you want to reschedule you are required to do so with in 2 weeks. If you do not reschedule with in 2 weeks we will discharge you from our services.


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