Please read this information carefully in order to provide your informed consent for undertaking counselling with Katie Empson. If you have any questions, please discuss them with Katie via email info@counsellorkatie.com.au  

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I confirm that by booking this appointment, I consent to the terms and conditions held by Katie Empson (hereafter referred to as Counsellor Katie or the counsellor) as stated below: 

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By booking an appointment, I am consenting to obligations of the cancelation policy stated here: 

1. I understand that by booking an appointment, I now assume all responsibility over session bookings and cancellations.

2. I understand that under the Victim Services scheme I can change or cancel my appointment with at least one (1) business days’ notice before my appointment time. Missed appointments are defined by Victim Services as "appointments where the client did not attend and did not provide more than one business days’ notice".

3. I understand that under the Victim Services scheme that if I miss two (2) appointments, the counsellor must elect whether to continue counselling or choose to stop counselling sessions going forward. I understand that if this occurs the counsellor will inform me of the outcome and will refer me back to the Victim Services website list of Approved Counsellors to select a new Approved Counsellor.

4. I understand that if the counsellor needs to cancel or change my appointment I will be contacted as soon as possible and will be offered the option to either reschedule or cancel the session. 

5. I understand that if I repeatedly miss or cancel appointments, the counsellor may choose to terminate counselling services. 

6. I understand that if I am running late, I must contact the counsellor as soon as possible. I understand that the time I miss from my allocated appointment time will be forfeited and the session will end at the scheduled time.

7. I understand that the session will remain open for 20 minutes from the scheduled start time. I understand that if I am more than 20 minutes late the session, I will be considered a 'missed appointment.'

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By booking an appointment, I am consenting to obligations of the age and location policy stated here: 

1. I understand that Counsellor Katie can only offer counselling services to those living in Australia. By booking this appointment I am confirming that I am currently living in Australia.

2. I understand that clients under the age of eighteen (18) require consent from a parent/guardian to engage in counselling with the counsellor. By booking this appointment I am confirming that I am either eighteen (18) or older; or can provide consent from a parent/guardian; or I am a parent/guardian booking on behalf of their young person.

3. I understand that as a parent/guardian that, I am required to disclose any legal, court or parenting orders that the counsellor should be aware of that may affect my young person’s care or well-being.

4. I understand that telehealth counselling should be done in a private, safe space. I understand that if I am in an inappropriate or unsafe environment for counselling (such as, but not limited to, operating a motor vehicle, or in an open public area) that the counsellor reserves the right to reschedule the appointment.

5. I understand that any breech in this agreement may result in the counsellor terminating counselling services.
    

Time Zones: 

1. I understand that I am I am responsible for ensuring that I am using the correct time zone for my appointment booking. Counsellor Katies default time zone setting is local Sydney, Australia time.

2. I understand that any appointments missed due to failure to consider time zones is subject to the cancellation policy and the late no-show policy. 
    

By booking an appointment, I am consenting to obligations of the privacy and confidentiality policy stated here: 

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Privacy and confidentiality:
As part of the provision of service to you, including but not limited to counselling, assessment, treatment, and report writing, Counsellor Katie needs to collect and record personal information from you. In accordance with relevant privacy and confidentiality legislation, the information collected may include (but may not be limited to) your name, contact details, medical history, employment status and other relevant information as appropriate. The collection of this information is a necessary part of your participation in Counselling. Your informed consent must be given prior to commencement of services.

Privacy and Confidentiality:
our personal information is gathered as part of the service you are engaging in. Information is securely stored and is retained in order to document what occurs during sessions. This helps the counsellor to provide a tailored service specific to your needs.

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Limits to Confidentiality

All personal information gathered by Counsellor Katie during the provision of services remains confidential except when:

1. It is subpoenaed by a court; or

2. Failure to disclose the information would, in the reasonable belief of Counsellor Katie place you or another person at serious risk to life, health or safety; or

3. Your prior approval has been obtained to a) provide a written report to another professional or agency; b) discuss the material with another person; c) disclose the information in another way; or

4. You would reasonably expect your personal information to be disclosed to another professional or agency 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.
    

Consequence of Not Providing Personal Information:

If you do not wish for your personal information to be collected in a way anticipated by this consent form, Counsellor Katie may not be in a position to provide the counselling service to you and may choose to terminate counselling services.

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By booking an appointment, I am consenting to obligations of the telehealth policy stated here: 

A telehealth service is a therapy service that is conducted via a secure video platform. The purpose of the session may include but is not limited to counselling, assessment, supportive intervention, and onward referral.

1.  I understand that there are laws that protect my privacy and the confidentiality of my personal information apply to telehealth sessions.

2. I understand that Counsellor Katie has chosen a telehealth software platform which meets the recommended standards to protect the privacy and security of the consultation.

3.  I understand that there are potential risks and consequences of participating in telehealth consultations, including technical difficulties such as internet connection limits.

4.  I understand that telehealth consultations will not be exactly the same as a direct visit due to the fact that I will not be in the same room as my healthcare provider.

5.  I agree that neither myself nor my practitioner will record the sessions.

6. I understand that telehealth consultations do not provide emergency services. If I am experiencing an emergency, I understand that I can call 000 or Lifeline (13 11 14) for crisis and suicide support.

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Record of Attendance: 

I understand the counsellor must maintain evidence of the service provided. I understand the counsellor will keep an attendance sheet, which details the date, time and nature of the service provided. I understand this information must be readily produced by the counsellor to Victim Services at request. I consent and give permission for the counsellor to mark attendance on my behalf by using my initials. I understand I can request to see this information at any time.