Robbie Spence MACA (Clinical)

Clinical Counsellor

storyaboutjake.com

CLIENT FORM

Counselling Services

As part of providing a Counselling service to you, your counsellor, Robbie Spence, will need to collect and record personal information from you that is relevant to your current situation. This information will be a necessary part of the assessment and treatment that is conducted.

 

Confidentiality

All personal information gathered by the counsellor during the provision of the counselling service will remain confidential

and secure except when:

1. It is subpoenaed by a court of law

2. Failure to disclose the information would place you and/or another person at risk of harm

3. Your prior approval has been obtained to …

a. provide a written report to another professional or agency eg a GP, other health care professional, lawyer or

supporting agency such as Workcover or Third Party Insurance agency

b. discuss the material with another person eg referring GP, parent, partner or employer.

Fees

The cost of initial consultation is $40 (phone) and successive consultations is $150 (1 hour session) or $250 (in-home). Sessions that go over 1 hour will charged at $40.00 per quarter hour or part thereof (consultations are GST exempt). An invoice and link to pay for session fee will be emailed to you following your session. Payment must be received within 5 days of receiving your invoice.

Cancellation & Late Policy

If, for some reason, you need to cancel or postpone the appointment, please give at least 24 hours notice. Failure to do so

may incur an administration fee up to the scheduled fee, depending on time of notice of cancellation e.g. a client who simply

does not show will be charged the full fee. In situations where the client arrives late, the duration of session will be the

scheduled session period.

Charter for Clients of Counsellors

As a client of a counsellor, you have a right to expect that:

• You will be treated with respect

• You will receive a clear explanation of the service you will receive

• Your consent for any service will be sought by the counsellor prior to the service commencing and as it progresses

• You will receive an explanation about the nature and limits of confidentiality surrounding the service

• You will receive competent and professional service

• You will receive a clear statement about fees

• You will be clear about the outcome that you and the counsellor are working toward

• You will receive a service free from sexual harassment

• You will be shown respect for your cultural background and language tradition

If you have any concerns about the conduct of your counsellor, call the Australian Counselling Association on 1300 784 333.

Client Consent Form Agreement

Thanks for submitting!