Client Information & Consent Form · Ember & Oak Therapy

Client details

Name

Date of birth

Phone

Address

Emergency contact

Relationship

Phone

Therapy

Therapy is a collaborative process designed to support your emotional wellbeing and help you work towards your personal goals. While therapy can be highly beneficial, outcomes vary between individuals and no specific results can be guaranteed.

You are encouraged to actively participate in sessions and discuss any concerns, questions or feedback throughout the therapeutic process.

Confidentiality

Your privacy is extremely important. Information shared during therapy will remain confidential unless:

You provide written consent for information to be shared.
There is concern that you or another person is at immediate risk of serious harm.
Information is required by law (for example, mandatory reporting obligations, subpoena or court order).
Information is shared for professional supervision or consultation. Your identifying information will be removed wherever possible.

If confidentiality ever needs to be breached, this will be discussed with you whenever it is safe and appropriate to do so.

Communication

You are welcome to contact Ember & Oak Therapy by phone or email regarding appointments or administrative matters. Please note:

Email and SMS are not suitable for urgent mental health concerns.
Clinical advice is generally provided during scheduled appointments.
Messages will be responded to as soon as practical during business hours.
Ember & Oak Therapy is not a crisis service and does not provide after-hours support.

If you require immediate support, please contact your GP, your local Mental Health Triage Service at South West Healthcare on 1800 808 284, Lifeline on 13 11 14, or call 000 if you are in immediate danger.

Telehealth

Where appropriate, appointments may be provided via secure telehealth. By participating in telehealth sessions, you acknowledge that:

You have access to a private space.
You understand there may be occasional technical difficulties.
Every reasonable effort will be made to maintain your privacy and confidentiality.

Client responsibilities

As a client, I understand that I am responsible for:

Attending appointments on time.
Providing at least 48 hours' notice if I need to cancel or reschedule.
Paying applicable fees as outlined in the Fee Agreement.
Providing accurate and up-to-date personal information.
Informing my therapist if my contact details change.

Social media

To protect your privacy and maintain professional boundaries, Ember & Oak Therapy does not accept friend or follow requests on personal social media accounts, or engage in therapy via social media messaging.

Privacy

Ember & Oak Therapy collects personal information necessary to provide safe and effective mental health care. Your information is securely stored in accordance with Australian privacy legislation and professional standards. Clinical records are retained in accordance with applicable legal and professional requirements before being securely destroyed. The full privacy policy is available on this site.

Consent

Please read each statement and tick to indicate your agreement. All of these are needed before therapy can begin.

I have read and understood the information provided.

I understand the limits of confidentiality.

I understand the nature and purpose of therapy.

I understand the cancellation policy and fee agreement.

I consent to receiving therapy from Ember & Oak Therapy.

I consent to communication via email and SMS regarding appointments and administrative matters.

I consent to telehealth appointments where appropriate.

I have had the opportunity to ask questions and have them answered to my satisfaction.

Optional consent

Tick any of these you are happy to agree to. Leaving them unticked will not affect your care.

My GP may receive relevant treatment updates where clinically appropriate.

I consent to communication with other healthcare providers involved in my care where appropriate.

I consent to my therapist leaving voicemail messages regarding appointments.

I consent to appointment reminders via SMS and/or email.

Signature

Typing your full name below acts as your electronic signature. The date and time of signing are recorded automatically when you send this form.

Type your full name to sign

Is the client under 18 years of age?

NoYes

Parent or guardian consent

I confirm that I am the parent or legal guardian of the client named above and consent to them receiving counselling services.

Parent/guardian name

Relationship to client

Phone

Type your full name to sign

Your answers are emailed straight to Amy Inglis and are not stored on this website. Email is convenient but never completely secure — if you would rather not send something in writing, leave it blank and raise it in session instead. How your information is handled is set out in the privacy policy.

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