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Forms for completion prior to treatment

Please complete the following three forms on this page prior to your first session: Client Intake Form, Client Consent Form and Telehealth Consent Form. It is also important to read and understand our Cancellations Policy and Privacy and Data Collection Policy.

Desert Nature
intake

Integration Therapies Client Intake Form

Welcome to Integration Therapies. In order to help your practitioner prepare for your first session, please complete the following form.


All information collected online or during sessions is strictly confidential and securely stored. For more information on our Privay and Data Collection Policy visit https://www.integrationtherapies.com.au/english-privacy-policy.


If you have any questions or are unsure what to write, please let us know.

Date of birth
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Year
Multi-line address

Payment information


Payment is required prior to your appointment and can be made at https://www.integrationtherapies.com.au. See our Cancellation Policy also on our web page.

Use of Integration Therapies contact information


The use of Integration Therapies' phone and email address is only for appointment setting and other general essential, non-therapy based communication. Integration Therapies will not respond to personal, therapeutic or crisis outreach unless previously arranged. If you are in need of crisis counselling or support, please contact a crisis or emergency services in your area.

I have read and understood this Intake Form and agree to the stated terms and conditions of service.

Date
Day
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telehealth

Telehealth Consultation Consent Form

Definition

A telehealth service is a therapy service that is conducted via the telephone or secure video platform, such as ZOOM or Microsoft Teams or similar. The purpose of the session may include but is not limited to counselling, psychotherapy, assessment, supportive intervention and onward referral.


Instructions

Please read this form carefully in order to provide your informed consent for undertaking telehealth consultations with Andrew Integration Therapies. If you have any questions, please discuss them with your practitioner prior to the session.


Telehealth Consultation Consent

  1. I understand that there are laws that protect my privacy and the confidentiality of my personal

information apply to telehealth sessions.

  1. I understand that my practitioner has chosen a telehealth software platform which meets the

recommended standards to protect the privacy and security of the consultation.

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

  2. 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.

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

  4. I understand that telehealth consultations do not provide emergency services. If I am experiencing an emergency, I understand that I can call a crisis and/or suicide support phone line.

Consent


I have read and understood this Telehealth Consultation Consent Form, and agree to the above conditions for the telehealth service provided by Integration Therapies.

Date
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Year

If client is under 18 years of age

Date
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consent

Integration Therapies Client Consent Form

As part of the provision of service to you, including but not limited to counselling, psychotherapy, assessment, treatment and report writing, Integration Therapies 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 mental health counselling and/or therapy. Your informed consent must be given prior to commencement of services.


Privacy and Confidentiality

Your 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 our service to provide a tailored service specific to your needs.


Limits to Confidentiality


All personal information gathered by Integration Therapies 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 Integration Therapy 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

  1. 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

  1. 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, Integration Therapies may not be in a position to provide counselling or therapeutic services to you.


Consent


I have read and understand this Consent Form and agree to the above conditions

Date
Day
Month
Year

If client is under 18 years of age

I provide consent for the exchange of verbal and written correspondence about my child’s service at Integration Therapies be provided to:

Date
Day
Month
Year
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