New client intake & consent form
Please read the following information and then fill out the intake and consent form at the end to assist me in understanding you and your concerns and to acknowledge and agree to the conditions of therapy set out herewith.
All information will be held confidentially as detailed below.
As a member of HTA, my code of ethics articulates and promotes the ethical principles, and set specific standards to guide both Arts therapists, and members of the public, to a clear understanding and expectation of what is considered ethical and professional contact by Arts therapists. The code affirms the ardent pursuit of professionally responsible actions and the appraisal of ethical issues and the implications, so the arts therapists provide services that are ethically sound and therefore in the best interests of our clients.
As an Arts Psychotherapist, I am committed to the absolute welfare of my clients and to the preservation of your human rights and privileges. There are three key principles based around this commitment.
1/ Professional Responsibility:
As an Arts Psychotherapist, I will support and further the goals of the profession by acting with integrity in maintaining the highest standards of creative arts therapy practice.
As an Arts Psychotherapist, I seek to be informed about the significance of respecting, understanding and considering the meanings of indigenous cultures in their work. We recognise the unique position of aboriginal people in Australian culture and history. We recognise that aboriginal peoples as the first nation peoples of Australia, who are the original custodians of the land. This cultural sensitivity applies to individuals who identify in the communities as a person of Aboriginal or Torres Islander descent.
As an Arts Psychotherapist, I recognise and respect cultural differences and diversity among people, and oppose discrimination and oppressive behaviour.
If it is apparent that I am unable to be of professional help to a client, I will not start treatment or seek to terminate treatment if it has already begun, while offering assistance in seeking satisfactory alternate services for the client.
As an Arts Psychotherapist, I am obligated to maintain continuing professional education, which includes seminars/conferences/reading/teaching etc to continue to relate to all aspects of being a creative arts therapist including the need to maintain a personal creative practice.
2/ Confidentiality/Privacy/Rights:
Arts Psychotherapists have a primary responsibility to respect and honour client confidentiality and to safeguard all written, typed, digitally recorded, and visual work, or information produced during the course of therapy.
The services I provide are bound by the legal requirements of the National Privacy Principles Act 2000, the Victorian Information Privacy Act 2000 and the Victorian Health Record Act 2001. These Acts describe your rights and how your information should be handled. You can access a full copy of these at www.legislation.gov.au and www.legislation.vic.gov.au.
As an Arts Psychotherapist, I must obtain each and every client’s permission before any verbal, written, typed, recorded, visual or other information is shared outside of that mentioned above. When permission has been given by the client, I will remove all identifying information, so as to ensure that information revealed is accurate and unbiased, and directly relates to the client’s therapeutic relationship with the therapist.
I will not breach confidentiality without client consent unless mandated by law, or when a client’s mental or emotional state clearly indicates an immediate danger to the client and/or others. In such cases, I must act in accordance with the law, and document the event, while at all times respecting the client’s dignity.
3/ The Service I provide: Creative Counselling:
I provide on-line sessions only.
All you need is a mobile phone, laptop or landline.
I use Teams or Facetime as my preferred platform as they are secure. If you have a preferred software such as Zoom, this can be discussed.
Client’s Rights:
To have all religious, spiritual and cultural beliefs respected
To be given the choice to engage in creative experiences
The right to be treated with respect and courtesy at all times
The right to feel safe and heard within their environment
The right to privacy and confidentiality with information shared
The right to be informed about the service or to withdraw at any time
Client’s Responsibilities:
To treat the Arts Psychotherapist with respect and courtesy
To freely open up and not hide any aspects so that I can work with you to find more meaning and new knowings
To choose a suitable environment to engage on-line that provides privacy in their home or setting of their choosing
To please inform me if you are unable to attend appointments
Personal information:
All personal information gathered by me during therapeutic sessions will not be disclosed outside of my practice except when:
Failure to disclose information which would, in the reasonable belief, place you or another person at serious risk to life, health or safety: or
It is subpoenaed by a court: or
Your prior approval has been obtained to discuss this material with another person. e.g. parent, lawyer: or
Disclosure is otherwise required by law.
Your personal information will not be used, sold, rented or disclosed for any other purpose.
Where is information kept:
I take all reasonable steps to hold your information securely to protect your personal information. Any electronically held information is retained securely with logins and passwords required.
Fees:
Therapeutic sessions for one hour are $120-$130.
Package and concession rates are available.
Cancellation policy:
If you need to cancel or postpone your appointment, I would appreciate at least 24 hour’s notice. Please call or text me on 0415 426417.
Care: when a session is confirmed “Yes” the night before, a late cancellation fee of 50% can apply for non-attendance. If within 15 minutes of the session start time, the full fee may be applied.
Feedback and Complaints Procedure:
If you have a concern about any aspect of your contact with me, I welcome you to discuss your concerns. If you are unsatisfied with my response and wish to make a complaint to an external party, I will provide you with contact details for the most appropriate legislative body.
If after reading this form you are unclear about any of the information provided, please feel free to contact me to discuss further.