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, Matthew Simmond at the Child Development Network (CDN).

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 records shared which relate to your child.

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

Information Use in Professional Group Settings

Client information may also at times, with client consent, be used in a non-identifying manner during training or professional development activities within professional group settings. If you do not wish this to occur, then please tick the box below.

Audio Recordings of Sessions

In line with the Australian Health Practitioner Regulation Agency requirements, allied health professionals are required to take accurate, up-to-date, factual and legible records. To ensure that this standard is met, your psychologist currently utilises Lyrebird Health, an AI medical scribing tool. AI scribing tools summarise notes from audio recordings of sessions and improve on the accuracy of notes made and increases the amount of time your psychologist can spend planning out future sessions.

Please note that processing completed by this software, such as speech-to-text transcription, redaction, and storage of your information is all securely done on Australian shores in compliance with privacy legislation. Audio files are immediately destroyed upon their transcription by AI and transcripts are stored such that personal identifying information is redacted. Post-redacted transcripts are further encrypted using AES-256 bit bank-level encryption to ensure the highest level of protection.

Please indicate your consent below for AI scribing software to be used for your sessions.

Communication

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

Fee for Services

Your psychologist, Matthew Simmond, charges $255.00 per hour for their time. In extenuating circumstances this fee may be reduced at the discretion of Matthew Simmond upon written request by the client to the Child Development Network.

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 Matthew Simmond at CDN.

The services and appointments provided by your psychologist from 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 CDN.

If you wish to discuss the waiver of the fee, please send a written request. Letter or email are acceptable requesting the fee to be waived with an explanation to the Practice Manager. 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 rebookings or missed appointments, their clinician may return their care to their GP and they will no longer be offered appointments through the CDN.

Child Minding Policy

The CDN administrative staff are not in a position to provide child care or supervise your child.

If you anticipate that your child might be required to spend time in the waiting room without you, and would require supervision during that time, then please 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.

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