Mental Health Information & Consent Form

Download the PDF form here or fill the form online below.

"*" indicates required fields

Client Information

Name*

Phone*

Email*

Date of Birth*

Emergency Contact

Contact 1:

Name*

Phone*

Relationship to Client*

Contact 2:

Name

Phone

Relationship to Client

I understand that the purpose of counselling is to address concerns, improve mental health, enhance coping skills and wellbeing. I agree to work collaboratively with my counsellor to establish goals for counselling and to actively participate in the therapeutic process.

Confidentiality: I understand that all information shared in counselling sessions is confidential, except in the following circumstances:

When there is a risk of harm to myself or others
When there is suspected abuse or neglect of a child, elder, or vulnerable adult
When disclosure is required by law or court order

Limits to Confidentiality: I understand that my counsellor may consult with supervisors or colleagues to ensure the quality of services provided. In such cases, identifying information will be kept confidential.

Fees and Billing: I understand that counselling services may be subject to fees. I agree to pay for services rendered according to the agreed-upon fee schedule.

The cost of a 60-minute session is $193.99, which is due for payment on the day of the session. However, clients who have a Mental Health Care Plan will only be charged the gap rate of $112.09.

For more details regarding our fee schedule, see our Fees page or contact Healthy Mind

Medicare Details

Medicare Number*

Individual Reference*

Expiration*

If under the age of 18, please provide guardian claimant details below.

Medicare Number

Individual Reference

Expiration

Cancellation and Rescheduling: I understand that appointment must be cancelled or rescheduled at least 48 hours in advance, except in cases of emergency. I agree to adhere to the cancellation policy of Healthy Mind.

At Healthy Mind, our commitment lies in delivering quality services promptly. However, when clients cancel appointments without adequate notice or fail to attend ("No Show"), it hinders our ability to accommodate other clients. Therefore, we have instituted a cancellation policy.

wo days before your appointment, we send text message reminders. If you cannot attend, please contact Healthy Mind at (08) 8522 5042. While we understand the need for cancellations and emergencies, we kindly request a minimum of 48 hours' notice.

Please note that cancellations or missed appointments without 48 hours' notice will incur a 50% cancellation fee.

Informed Consent*

I have read and understand the information provided in this consent form. I voluntarily consent to participate in mental health counselling services provided by Healthy Mind.

Written consent

Verbal consent

Client / Client Representative Name*

Client / Client Representative Signature*

Date*

Time*