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Informed Consent and Confidentiality - Incolink Counselling and Support Service

Audio and Video Link (AVL) and Face-to-face COUNSELLING AGREEMENT

Several things are discussed in the first meeting between a counsellor and client. Asking you to sign this agreement is a simple way to ensure that:

1. you are aware of your rights and that you willingly consent to the counselling; and

2. know some essential things about how your information will be handled.

It is a requirement for clinicians to engage in regular internal clinical and external professional supervision to ensure their counselling work, service quality, and safety for the client and the counsellor are adhered to. I acknowledge my consent to receive counselling services from the counsellor I am assigned to.

I consent to engage in telehealth sessions and face-to-face by signing this agreement.

  • I, therefore, permit my counsellor to discuss, in supervision, issues related to the counselling being received. I am privy to knowing that my identity will not be revealed in the counsellor’s external clinical supervision.
  • I consent that the information I share in my sessions with the counsellor may be collected, used, stored and disclosed by the counsellor pursuant to Incolink’s Privacy Policy. I understand I may discuss confidentiality and consent with my assigned counsellor. I may withdraw this consent at any time by written notice; however, this may limit Incolink’s ability to provide me with further counselling and support services.
  • I understand that if my counsellor is concerned that there is a risk of immediate harm to myself or others, confidentiality may be broken to ensure safety. My counsellor will inform me if this occurs.
  • I understand the counsellor will take written records if/when required related to our work together, and I know that I may request access to those records. These records may be kept and destroyed seven (7) years after the counselling concludes.
  • I understand that there will be no fees for as long as I remain an active Incolink member - or my family member is an active Incolink member.
  • I understand that Incolink Counselling and Support Services provide short-term interventions unless agreed otherwise by Incolink.
  • I understand my counsellor may refer me to see my General Practitioner and direct me to an external agency should the clinician at Incolink not be able to continue with my treatment plan.
  • I understand that the counsellor has the right to decline to work with me should there be a conflict of interest or if it is unsafe to continue. The clinician will endeavour to refer me to another clinician in such an event.
  • I understand and acknowledge in exceptional circumstances, should my counsellor have good grounds to believe that serious harm may occur to me or other people and believe I am not willing or capable of taking responsibility for my actions that, it is my counsellor’s right to break confidentiality to ensure my or other’s safety. Normally, the decision to break confidentiality will be discussed with the counsellor’s supervisor and me or an experienced counsellor.
  • I understand the counselling relationship between my counsellor and myself may end when the help I received may not have worked or due to external circumstances which are not therapeutic. In such an event, my counsellor will plan for care to be taken of my immediate needs in the event of any sudden and unforeseen endings by the counsellor or breaks to the counselling relationship.
  • I understand that missed appointments without providing 24 hours’ notice will be deducted from the total sessions I am provided.
  • I understand that should I have a complaint about the counsellor or services, I should discuss it with my assigned counsellor or their clinical supervisor so we can effectively work through a solution. The complaint will be dealt with internally via Incolink’s Complaint Handling Process. If not resolved, it will be referred to and dealt with externally by the assigned counsellor’s governing body they are registered with.

Privacy Statement

The information we collect on this form is to enable us to provide services on the basis of correct and up to date information. Your personal information will be maintained securely. If you would like further information on Incolink privacy policy please contact the Management on (03) 9639 3000 or refer to our website.