Consent Form and Confidentiality Agreement

Name *

Email *

Address *

Phone Number *

Therapy requested *

Acceptance Commitment Therapy
Animal Assisted Therapy

Therapy requested

Briefly describe your goals: *

Consent & Conditions of Service Agreement

Yes, I have completed and agreed to all of the below required fields.

1/7: Referrals *

Yes, I accept that counsellors / Nurses have a duty of care to all clients and that I may be referred to a service other than this service if the counsellor / nurse (s) decide that they are unable to assist me.

2/7: Privacy *

Yes, I understand that as part of providing a service to myself it may be necessary to collect and record personal information that is relevant to my current situation. This information will inform a vital part of the assessment and how the session will be conducted. The information is gathered as part of the assessment, and to direct how the session is conducted and, is seen only by the Counsellor / Nurse. The information is retained in order to document what happens during sessions, and enables the Counsellor / Nurse to provide relevant and informed holistic services.

3/7: Access to Information *

Yes, I understand that at any stage me as a client is entitled access to the information about me kept on file, unless the relevant legislation provides otherwise. Dr. Geller may discuss with me appropriate forms of access. All personal information gathered by the clinician during the provision of service will remain confidential and secure, except where: it is subpoenaed by a court; failure to disclose the information would place you or another person at serious and imminent risk; your prior approval has been obtained to provide a written report to another professional or agency (e.g. a GP or lawyer), or discuss the material with another person; or disclosure is otherwise required or authorised by law.

4/7: Agreement of Inherent Risks (AAT) *

Yes, I have made myself aware of any risks involved (including potential allergic reactions to pet hair, any behaviours the dog may show that may cause discomfort, including licking, nipping, biting or other injuries). I understand that while every precaution is taken to minimise these risks, choosing Animal Assisted Therapy sessions will be at your own risk. OR
I am not engaging in Animal Assisted Therapy.

5/7: Service Acknowledgement *

Yes, I understand that the Services are offered in good faith and any advice or instruction provided in any interaction with clients may have and should not been seen by them as a substitute for the professional advice of medical doctors, psychiatrists or clinical psychologists. In all cases it is the responsibility of each client to seek appropriate professional treatment for any symptoms of disease or dis-order that they may be experiencing. Dr. Geller is not able to give any warranty or guarantee that personal problems (either expressed or implied) presented by a client can or will be resolved.

6/7: Responsibilities

Yes, I understand that Dr. Geller does not accept any liability or responsibility for any consequences of a client's use of its services - either beneficial or otherwise. A client's use of the advice or information provided in a counselling session, their interpretation of what they see or hear in such sessions or any effects on them or others which they attribute to such sessions is their responsibility alone.

7/7: Waiver of Liability

Yes, I understand that in no event shall Dr. Geller, Canine Essentials Pty. Ltd., Nursing Essentially or its employees be liable to any person(s) for any loss or damage of any kind which may occur as a result of the service(s) it provides.

Confidentiality Agreement *

Yes, I have completed and agreed to all of the below required fields.

It is understood and agreed to that the below identified discloser of confidential information may provide certain information that is and must be kept confidential. To ensure the protection of such information and to preserve any confidentiality necessary, it is agreed that:

1/5: Acknowledgement of Responsibilities and Information *

Yes, I have read and understood the described acknowledgement and what constitutes "Confidential Information" as described here.

It is the responsibility of all Nursing Essentially (NE) workforce members, as defined above, including: employees, sub-contractors, consultants medical staff and other health care professionals; volunteers; agency, temporary and registry personnel; and students (regardless of whether they are NE trainees or rotating through NE facilities from another institution), to preserve and protect confidential client, employee and business information. Nursing Essentially handles all information according to the Privacy Principles as described in the Australian Commonwealth Privacy Act (1988). This is clearly delineated on Nursing Essentially’s website at: http://www.nursingessentially.com.au/privacy-policy/ The client is advised that Nursing Essentially will only collect personal information necessary for our business functions or activities. This includes: o providing you with our services; o providing you with information you may have requested and answering your enquiries; o providing you with the information we consider of interest to you – but please remember that we will always ask for your permission first. Confidential Client Information includes: Any individually identifiable information in possession or derived from a provider of services regarding a client’s medical history, mental, or physical condition or treatment, as well as the clients and/or their family members records, test results, conversations, research records and financial information. Examples include, but are not limited to: o Physical medical and psychiatric records including electronic, paper, photo, video, diagnostic and therapeutic reports, laboratory and pathology samples; o Client insurance and billing records; o Drivers licence or photographic identification records; o Mainframe and department based computerised client data and alphanumeric radio pager messages; o Visual observation of clients receiving medical care or accessing services; and o Verbal information provided by or about a client.

2/5: Disclosure of Confidential Information *

The Recipient shall limit disclosure of Confidential Information within its own organisation to its directors, officers, partners, members, employees and/or independent contractors (collectively referred to as “affiliates”) having a need to know. The Recipient and affiliates will not disclose the confidential information obtained from the discloser unless required to do so by law.

3/5: Obligations for Confidential Information

Yes, I understand that this Agreement imposes no obligation upon Recipient with respect to any Confidential Information a. that was in Recipient’s possession before receipt from Discloser; b. is or becomes a matter of public knowledge through no fault of Recipient; c. is rightfully received by Recipient from a third party not owing a duty of confidentiality to the Discloser; d. is disclosed without a duty of confidentiality to a third party by, or with the authorisation of, Discloser; or e. is independently derived by Recipient.

4/5: Agreement Terms *

Yes, I understand that this Agreement states the entire agreement between the parties concerning the disclosure of Confidential Information. Any addition or modification to this Agreement must be made in writing and signed by the parties.

5/5: Modifiable Terms *

Yes, I understand that if any of the provisions of this Agreement are found to be unenforceable, the remainder shall be enforced as fully as possible and the unenforceable provision(s) shall be deemed modified to the limited extent required to permit enforcement of the Agreement as a whole.

Payment Agreement *

Yes, I understand that and I consent to the fees charged by Nursing Essentially and Dr. Geller respectively and understand that they are non-refundable subject to those terms stipulated by the Australian Competition & Consumer Commission “Consumer Rights & Guarantees”. Further, I understand that “no-shows” and cancellations (48 hours’ notice is required) count as sessions. Further, I understand that if fees are not paid, this may result in cancellation of future sessions and active collection of outstanding fees via debt collectors and/or the Australian legal system by Nursing Essentially and Dr. Geller respectively. Recovery of monies owed undertaken by Nursing Essentially and Dr. Geller respectively will be at my expense.

Client Acknowledgement of Terms and Conditions in its entirety *

Yes, I agree to all the Terms and Conditions as outlined herein in their entirety.

E-Signature *

This e-Signature typed here confirms that this Consent Form is a true and correct statement of fact and constitutes full agreement of terms and conditions as described herein.