Privacy Consent Form

a. The administrative purpose of running the practice.

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b.  Billing either directly or through an insurer or compensation agency.

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c.  Use within the practice if discussing or passing your case to another                practitioner within  the practice for your ongoing management.        

                                                                                                                                

d.  Disclosure of information to your doctors, other health professionals or          to  teachers to  facilitate communication and best possible care for you;        and

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e.  In the case of insurance or compensation claim it may be necessary to         disclose and/or  collect information that concerns your return to work to        an insurer or your employer.   

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We do not disclose your personal information to overseas recipients.

Stand Strong Child & Youth Counselling has a Privacy Policy that is available on request and is available on our website : www.standstrong.com.au

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The Privacy Policy provides guidelines on the collection, use, disclosure and security of your information. 

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The Privacy Policy contains information on how you may request access to, and correction of, your personal information and how you may complain about a breach of your privacy and how we will deal with such a complaint.

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To ensure the process of quality treatment provision, information about your assessment results and progress may be given to relevant other service providers, who are involved in your management. 
These may include your doctor, teachers, specialists, insurers, solicitors or employers. 

Please see below the collection of privacy form you will be asked to sign.   

I, ______________, have read the above information and understand the reasons for the collection of my personal information and the ways in which the information may be used and disclosed and I agree to that use and disclosure.
I understand that it is my choice as to what information I provide, and that withholding or falsifying information might act against the best interests of my assessment and therapy progress.
I am aware that I can access my personal and treatment information on request and if necessary, correct information that I believe to be inaccurate.
I understand that if, in exceptional circumstances, access is denied for legitimate purposes, that the reasons for this and possible remedies will be made available to me.
I have been provided with or have been given an opportunity to obtain a copy of Stand Strong Child & Youth Counselling's privacy policy.

I acknowledge that have been given a Stand Strong Child & Youth Counselling information brochure, which information has been explained to me by my clinician. I acknowledge that i understand and agree to the information in the Stand Strong Brochure.

Signed…………………………………………..Date……………………………………

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