Informed Consent Form

The following information attempts to ensure that you are aware of the issues relevant to the provision of counselling services by, as well as supervision for, your psychologist, Madeleine Ryals at the Child Development Network (CDN).

Psychological services are provided on the basis of informed consent. This means that you are entitled to receive sufficient information about the nature, purpose, benefits, risks and alternatives to the proposed services, and to ask questions before agreeing to proceed.

Consent is a voluntary decision and may be withdrawn at any time. Withdrawing consent may affect the services that can be provided and will be discussed with you if this occurs.

Consent will be reviewed if there is a significant change to the nature of services, treatment plan, recording practices, or information sharing arrangements.

Children and Young People
When working with children and young people, consent is generally provided by a parent or legal guardian. However, your psychologist will also consider the child’s age, maturity and capacity to understand the service and will seek the child’s assent wherever appropriate.

The views and wellbeing of the child will be taken into account in decisions about assessment, treatment and information sharing. In some circumstances, confidentiality between the psychologist and the child may be discussed and negotiated in the child’s best interests, within legal and ethical limits.

Confidentiality
As part of providing a professional service to your child (treatment services) it will be necessary to collect and record personal information from you and your child that is relevant to their current situation. This information will include written records and may also include photographic images and video or audio recordings.

Information may also need to be collected from various sources including teachers, allied health and medical professionals. This information will be a necessary part of the work between you, your child, and your psychologist and will assist in the provision of a quality service.

All personal information gathered by Madeleine Ryals during the provision of professional services will remain confidential and secure. Information will be released only when:

It is subpoenaed by a court,

• Failure to disclose the information would place the client or another person at risk; or

• Your prior approval has been obtained to:

  • Provide a written report to another professional or agency, e.g. a GP/lawyer/school;

  • Discuss the material with another person, e.g. a parent, school or employer etc.

Client information will, at times, be discussed in a non-identifying way with your psychologist’s supervisor or colleagues for the purposes of reflecting on practice.

Professional Services
Treatment involves the development and implementation of a psychological treatment plan that addresses the concerns of parents and caregivers and the needs of the child or young person. Treatment plans are developed collaboratively with the child (where appropriate) and family, and may include assessment, intervention, consultation and review.

Services are provided in accordance with evidence-based practice and professional standards.

Correspondence and Review of Documents
As this is a non‑urgent service, emails and correspondence from parents/guardians (unless relating to child safety or urgent matters) may not be read until the time of the scheduled appointment. This policy supports appropriate professional boundaries and protects clinician wellbeing.

Each standard one‑hour appointment includes up to 10 minutes for the clinician to review correspondence and documents and to complete clinical notes, allowing approximately 50 minutes of direct therapeutic contact.

If additional time is required to review emails or documents outside the scheduled appointment, this time may be billed per minute at the clinician’s standard rate with your agreement.

Separated Parents and Consent
Unless otherwise specified by a Court Order, both parents or legal guardians have equal authority to make decisions regarding a child’s health and treatment, regardless of marital status or attendance at sessions.

If one parent or guardian objects to treatment, services may be paused until agreement is reached or a Court Order is provided. Where parents or guardians are separated or divorced, separate consent forms are required unless a Court Order states otherwise.

Any relevant Court Orders must be provided prior to the commencement or continuation of services. Please contact administration to arrange separate consent forms if required.

The attending parent or guardian is responsible for informing the non-attending parent or guardian of appointment and treatment information. Appointments should not be scheduled without the knowledge of the other parent or guardian. Responsibility for notification rests with the parent or guardian who arranges the appointment, and the psychologist is not responsible for any failure to inform the other parent or guardian.

Court Orders
Your psychologist must share information with a parent/guardian unless a court order prevents it. Any court orders concerning your child must be provided to Madeleine Ryals, as they impact therapeutic care. Please indicate below:

Privacy, Records and Access to Information
Client information is recorded, stored and managed in accordance with relevant privacy and health records legislation. Records are stored securely and protected from unauthorised access.

You have the right to request access to your child’s clinical records, subject to legal and ethical exceptions. Requests must be made in writing and will be responded to in accordance with applicable legislation.

Records are retained for the minimum period required by law, being at least:

• Seven (7) years from the last entry for adult clients; and

• Until the child reaches 25 years of age for clients under 18 years.

You may withdraw consent for the collection, use or disclosure of information at any time, subject to legal obligations and the practical requirements of service provision.

Associated Parties and Information Sharing
In providing services, your psychologist may interact with associated parties such as parents, carers, teachers, schools and other health professionals.

The identity of the primary client, the role of associated parties, and the nature of information sharing will be clarified as part of the assessment and treatment process.

Information will only be shared with associated parties with your consent, unless required or authorised by law or necessary to prevent serious risk to the client or others.

Information Use in Professional Group Settings
In line with the Psychology Board of Australia’s Code of Conduct, all psychologists participate in regular supervision or peer consultation to ensure safe, ethical, and effective practice. During supervision, your psychologist may discuss aspects of their clinical work, including client cases. Any information shared about your young person’s assessment will be de-identified to protect confidentiality, and supervisors or peers are bound by the same professional and ethical obligations. If you do not wish this to occur, then please tick the box below.

Audio Recordings of Sessions
Heidi is an AI-assisted tool designed to allow your clinician to focus fully on you during your session while accurately capturing medical information, ensuring a comprehensive and precise record of your care. Only your clinician has access to your information, with strict access controls in place, compliant with Australian privacy laws, and systems certified to global standards such as SOC 2 and ISO 27001 to ensure data security and confidentiality. All data is stored locally in Australia, prioritising data sovereignty, security, and compliance with Australian data protection regulations. Heidi collects only essential information for providing services, operates transparently as outlined in its Privacy Policy, and safeguards your data by restricting its use, disclosure, and retention. No recordings of appointments are stored; conversations are transcribed in real-time, and any notes saved by your clinician are added to your Electronic Health Record in their Practice Management System. By ticking ‘Yes, I consent,’ you acknowledge that you have been informed about Heidi’s purpose, understand how your information is handled and protected, agree to its use for documenting your session, and know you can withdraw consent at any time. Please indicate your consent below for AI scribing software to be used for your sessions.

External Platforms Used for Therapeutic Services
In the provision of therapeutic services, Madeleine uses NovoPsych, an online assessment platform that helps measure symptom severity, identify treatment focus areas, and track progress. Identifying information, such as first name and date of birth, may be used on these secure platforms. Their Terms and Conditions and Privacy Policies are available on their website.

Telehealth Sessions
For clients with extenuating circumstances, telehealth appointments may be offered at the psychologist’s discretion. If notice of a missed appointment is received on the day, a telehealth session may be offered, but this may not always be appropriate depending on the client’s age, therapeutic goals, or session plan. If a telehealth option is not suitable, a late cancellation fee will apply.

Telehealth sessions must be conducted in a private, safe location; bedrooms, moving vehicles, and public spaces are not acceptable; failure to secure an appropriate location will result in cancellation and a late fee. Clients (or their guardians) are responsible for providing a charged, working device with a reliable internet connection and testing it before the session. By scheduling telehealth, you acknowledge and accept these responsibilities.

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

Fee for Services
Your psychologist, Madeleine Ryals, charges $235.00 per hour for their time. In extenuating circumstances this fee may be reduced at the discretion of Madeleine Ryals upon written request by the client to the Child Development Network. Emails can be sent to cdn@cd.net.au.

Please note that any services requested by the client outside of their 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. A verbal quote for any additional services outside of therapy will be discussed and agreed upon with the client. Any additional time outside of an original estimate required will be confirmed with the client prior to its addition to the service fee.

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 Madeleine Ryals at the CDN.

The services and appointments provided by your psychologist from the CDN 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 for 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 by Clinicians who consult at the CDN.

If you wish to discuss the waiver of the fee, please send a written request. Letters or emails are acceptable requesting the fee to be waived with an explanation attention to Madeleine Ryals. Emails can be sent to cdn@cd.net.au.

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

Recurrent Cancellations

The provision of high quality care to children, young people and families requires a commitment on the part of the 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 demonstrates a pattern (e.g. 3 episodes) of late cancellations, late rebooking or missed appointments, their clinician may return their care to their GP and they will no longer be offered appointments through the CDN.

Termination of therapy
Your clinician may need to discontinue or temporarily pause therapy in certain circumstances to ensure safe, ethical, and appropriate care, in addition to your right to withdraw. This may occur if a dual or multiple relationship arises that could compromise the therapeutic relationship or pose ethical risks, which may sometimes be managed with transparency but not always. So, it’s important to inform Madeleine immediately if you suspect any such situation.

Therapy may also be paused or ended if your needs exceed Madeleine’s scope of practice or require a higher level of care, she may refer you to a more suitable provider. Safety concerns, including risk of harm to yourself or others, or if the psychologist feels threatened, unsafe, or experiences abusive or aggressive behaviour, may also necessitate ending therapy and referring to an appropriate service. Throughout this process, Madeleine aims to provide advance notice where possible and support referral or handover to another clinician, ensuring that you and your young person receive ethical and appropriate support.

Concerns, Feedback and Complaints
If you have any concerns about the services provided, you are encouraged to discuss these with your psychologist in the first instance so that they may be addressed promptly. For clients seeing Madeleine at the CDN you may also contact the Practice Manager via cdn@cd.net.au .

You also have the right to make a complaint to external bodies, including:

• The Psychology Board of Australia / AHPRA – www.ahpra.gov.au

• The Office of the Australian Information Commissioner (for privacy matters)

Raising a concern will not affect your child’s access to care.

Child Minding Policy
The CDN administrative staff are not in a position to provide childcare or supervise your child.

If you anticipate that your child might be required to spend time outside of the consultation room without you, and would require supervision during that time, thenplease arrange for a suitable adult to attend your consultation with you, so that they can be with your child as they wait.

If you are unsure if this applies to your circumstances, then please ask your Clinician or the administration staff prior to your visit.

Consent
I confirm that I have read and understood this Consent Form. I have had the opportunity to ask questions and receive clarification. I understand the nature of the services, confidentiality and its limits, recording practices, communication methods, fees and cancellation policies, and my rights regarding consent and withdrawal of consent.

I provide informed consent for psychological services to be provided by Madeleine Ryals to the child named below in accordance with this document.

Please note: If, after reading this page you are at all unsure of what is written, please discuss it with your therapist.