Service Consent Form

The following information attempts to ensure that you are aware of the issues relevant to the provision of counselling services by your psychologist, Lucinda Hinckfuss.

1. Professional Services
Treatment Services: Treatment involves the development and implementation of a psychological treatment plan that addresses the concerns of the parents/guardians, and the needs of the child. Psychological treatment plans are developed collaboratively with the child and family.

2. Fee for Services
Your psychologist, Lucinda Hinckfuss, charges $260.00 per hour for their time. Please note that any services requested by the clients or parent/guardians outside of the appointment time including but not limited to reports, telephone calls to other allied health professionals, or letters, is billed per minute that this service requires.

In extenuating circumstances this fee may be reduced at the discretion of Lucinda Hinckfuss upon written request by the client marked Attention to Lucinda Hinckfuss and email sent to the appropriate contact (see section 11 for contact information).

3. Correspondence
In line with best practice standards, and as a non-urgent service, any emails from parents/guardians unless urgent (i.e., relating to child safety) will not be read until the time of the appointment. Although the importance of individual client matters and correspondence with parents/guardians is greatly appreciated, there is simply not enough time during practising hours with fully booked days to get through the volume of emails that are received. This standard seeks to ensure that appropriate boundaries are maintained between the client and practitioner and to protects the mental health of your psychologist.

The time taken to go through any additional documents/emails will be taken out of the appointment time at the start of the appointment unless the parent/guardian is willing to compensate for the time it takes to read and make appropriate notes with an additional fee. Any additional fees will be charged by the minute in accordance with your psychologist’s standard rate.

4. Child/Adolescent Consent (Assent)
For clients under 18, consent is required from parent/s or legal guardian/s. We also seek the agreement (assent) of the child or young person to participate in the therapy process. If at any time a young person explicitly does not wish to continue, your psychologist will respect their wishes and discuss how to manage this and the next steps with you.

5. Separated Parents/Guardians

5.1 Provision of Therapy
Unless deemed otherwise by Court Order, both parents/guardian have an equal right to make decisions about their young person's health and treatment. This is so whether or not parents/guardians are separated or divorced at the time of, or subsequent to, engaging psychological therapy services for their young person, and whether or not both parents/guardians attend session(s) with their young person.

As such, if one parent/guardian objects to therapeutic services, your psychologist will need to consider ceasing until there is agreement from both parents/guardians or there is a Court Order addressing the matter. Due to this all parents/legal guardians who are separated or divorced are required to complete separate consent forms unless otherwise indicated by Court Orders. Court Orders must be provided to your psychologist.

Please contact the administrative team to have separate consent forms sent to the parent/legal guardian.

5.2 Information Sharing Between Parents/Guardians
It is the attending parent/guardian’s responsibility to ensure that information pertaining to the appointment is passed onto the parent/guardians who is not in attendance.

Further, it is important to note that your psychologist advises against any appointments being scheduled with the psychologist without the knowledge of the other parent/guardian. However, please note that it is the responsibility of the parent/guardian who scheduled the appointments, to inform the other parent/guardian, and your psychologist does not take responsibility for any failures on one parent/guardian’s part to alert the other parent/guardian.

5.3 Court Orders
Your psychologist cannot withhold information from a parent/guardian unless there is a court order in place with that has been received by your psychologist. It is a requirement of your psychologist, that any court orders related to your child, are forwarded to Lucinda Hinckfuss, as this directly relates to the provision of therapeutic care. Please indicate below if there are any court orders in place that relate to your child.

6. Mental Health Care Plan Referrals

A Mental Health Care Plan (MHCP) enables clients to claim Medicare rebates for up to 10 individual sessions with an eligible mental health professional per calendar year. To access MHCP Medicare rebates, clients must first obtain a MHCP from their General Practitioner (GP).

Upon completion of the sessions allocated under the current MHCP, your psychologist will provide a progress letter to your GP and, where appropriate, request a review or renewal of the MHCP to access any remaining eligible sessions for the year.

Please note that it is the psychologists and the client’s parent/guardian’s mutual responsibility to keep track of the number of sessions used under their MHCP. However, it is the client parent/guardian’s responsibility to ensure that a new or updated MHCP has been obtained from the GP if they wish to continue receiving rebates. If a valid MHCP is not in place at the time of an appointment, the session will be billed at the private rate until an updated MHCP is received.

7. Communication

Please confirm if you consent to receive communication, letters, reports and results by telephone, post, email or SMS.

8. Late Cancellation, Rescheduling and Non-attendance Policies

The intention of this policy is to allow for appointment gaps created by cancellations and rescheduling to be offered to other families in need of the services provided by Lucinda Hinckfuss.

The services and appointments provided by your psychologist are highly specific and involve several years of training and professional development. As such these services are in high demand. However, if you cancel or reschedule an appointment at late notice, or do not attend a booked appointment, we are unable to re-fill the appointment time slot.

For these reasons, all appointments that are cancelled or rescheduled with less notice than 2 full business days will be charged a late cancellation/ rescheduling fee of 100% of the booked consultation.  Likewise, if you do not attend a booked appointment, you will be charged a non-attendance fee of 100% of the booked consultation. This fee is not eligible for a rebate from Medicare. This fee must be paid before any further services are provided.

If you wish to discuss the waiver of the fee, please send a written request. Letter or email is acceptable requesting the fee to be waived with an explanation Attention to Lucinda Hinckfuss.

Any final decision to waive the late cancellation, rescheduling or non-attend fee is made by Lucinda Hinckfuss. It cannot be done by the administrative staff.

9. Recurrent Cancellations

The provision of high-quality care to children, young people and families requires a commitment on the part of the individual/family to the therapeutic process, including attending appointments at the time intervals recommended by their therapists and clinicians.

Clinicians recognise that sometimes circumstances may change at short notice and that this may prevent the family’s capacity to attend a scheduled appointment, however a pattern of recurrent cancellations can be detrimental to the child and young person’s clinical care and the therapeutic process as a whole. It can also prevent other families from accessing this valuable service.

For these reasons, if a family/individual demonstrates a pattern (e.g. 3 episodes) of late cancellations, late re-bookings or missed appointments, their clinician may return their care to their GP, and they will no longer be offered appointments.

10. Reasons why your clinician may need to discontinue therapy.

In addition to your right to withdraw, there are circumstances when Lucinda, as your psychologist, may need to end or temporarily pause therapy. These are all centred around safe and ethical practice and ensuring your young person receives support that is most suited to your needs and circumstances, in an ethical, sustainable, and neuroaffirming way. Where possible, Lucinda will provide advance notice and support referral or handover to another clinician if required.

10.1 Dual or Multiple Relationships:
If your psychologist becomes aware of a dual relationship that could compromise the therapeutic relationship or is considered high risk or unmanageable ethically, they may need to end therapy. Sometimes these situations can be managed with transparency and discussion, but not always. If at any time you think we may have any dual relationships, please let Lucinda know immediately so we can discuss whether it is manageable.

10.2 Failure to Pay:
If you lose your source of funding for sessions or are unable to pay on the day of appointment, please advise as soon as possible. Lucinda is unable to proceed with further sessions until payment is resolved or alternative arrangements are made.

10.3 Higher Level of Care or Different Service Required:
If, in your psychologist’s clinical judgment, you require a higher or more intensive level of care, or if your needs are outside their scope of practice, experience, or expertise, they may end therapy and refer you to a more suitable provider.

10.4 Safety Concerns:
If there are safety concerns that cannot be managed within a private practice context (e.g., risk of harm to self or others), your psychologist may need to end therapy and refer you to a more appropriate service.

Similarly, if your psychologists feel threatened, unsafe, or experiences abusive or aggressive behaviour, they will end the assessment process.

If you have any questions or concerns about this process, please let discuss these with your psychologist. Lucinda's goal is to ensure you and your young person receive ethical, appropriate, and affirming support throughout your assessment experience.

11. Emergencies
Please note that your psychologist does not and cannot provide crisis or emergency support. In an emergency/if you are seeking urgent support, please go to the nearest hospital’s emergency department, or call Emergency Services on 000. For further information, please refer to the website for your local health district. You may also find it helpful to call LifeLine on 13 11 14 for out-of-hours support.

12. Contact Information
See below for the appropriate contact details for Lucinda’s practice at the Child Development Network Milton. Lucinda does consult at another location at Red Hill. Please note that due to administrative demands, clients will be redirected toward the appropriate contact pathways should they use contact details for the incorrect location.

Child Development Network
Level 2 19 Lang Parade
Milton QLD 4064

Phone: (07) 3369 3369
Email: cdn@cd.net.au

13. Feedback and Concerns
You are encouraged to discuss any concerns or positive feedback about your service directly with your psychologist. For clients seeing Lucinda via the Child Development Network, you may also contact the Practice Manager via cdn@cd.net.au .

If your concern cannot be resolved, you may then contact:
Australian Health Practitioner Regulation Agency (AHPRA)
Phone: 1300 419 495
Website: www.ahpra.gov.au

14. Telehealth Appointments
For clients with extenuating circumstance, telehealth appointments may be offered at the discretion of your psychologist. In the event of a client being unable to attend their appointment and notice of this is received on the day, your clinician may offer a telehealth appointment. However, depending on the therapeutic goals, age of the client, and/or outline for this session, this may not always be appropriate. As such, failure to attend a scheduled appointment will still incur a late cancellation fee should your clinician elect not to offer a telehealth appointment.

Please note that in line with best practice, it is required that any telehealth appointments that are conducted are done so with the client in a private and safe location. Bedrooms, moving vehicles, and public settings will not be considered acceptable locations, and failure to find an appropriate location will result in the cancellation of the telehealth appointment with a late cancellation fee billed to the client.

Further, it is the responsibility of the individual client (or adult guardian) to ensure they have access to a charged working device (such as a computer, tablet, or smartphone) with a reliable internet connection. It is the client’s (or adult guardian’s) responsibility to test their device and connection prior to the scheduled appointment to avoid disruptions. By scheduling and attending telehealth sessions, you acknowledge and accept these responsibilities and conditions.

15. Collaboration with External Supports
Please note that progress updates and recommendations to external professionals (e.g., teachers, paediatricians, or other support providers) are not automatically included as part of your child’s therapy, except in the case of Mental Health Care Plan reviews to a client’s doctor.

While it is often beneficial for your psychologist to work collaboratively with other professionals involved in your child’s care, this process requires significant time outside of scheduled appointment sessions. Therefore, any additional correspondence with external supports will incur an extra fee, based on the time required.

If you would like specific supports to be included as part of your child’s therapy, please complete the table below. Contact with any nominated supports will only occur with your prior written consent and following a discussion with your psychologist.

Please confirm that you have read, understood, and consent to this Service  Policy as outlined above. Should you have any questions about this form please contact Lucinda Hinckfuss.

Any modifications to this agreement must be mutually agreed upon in writing by yourself and your psychologist. This consent is valid for a period of 1-year, and will be reviewed when requested, if the nature of your therapy needs change, or after a period of 1-year maximum. By signing below, you acknowledge you have read and understood the information above and have sought clarity from Lucinda Hinckfuss where you have had questions.