Client Intake and Consent

This form is to be filled out prior to your first appointment. Please fill it out as accurately as possible, as this will help our staff get your appointment confirmed easily, and save you time when you arrive at the clinic.

If you’re unsure about anything it’s alright to discuss it with reception staff or your Psychologist before or during the session.

Please take a couple of minutes to read the clinic conditions.

Do you consent to communication from Mind Potential Psychology? This may be in the form of email, text or voicemail messages.

Please Note: If, after reading this form you are at all unsure of what is written, please discuss it with your Psychologist..

I have read and understood the office policy on this page. I agree to these conditions for the psychological service provided. Please tick the box to accept the conditions.



Psychological Service

As part of providing a psychological service to you, we will need to collect and record personal information from you that is relevant to your current situation. This information will be a necessary part of the psychological assessment and treatment that is conducted. You do not have to give all your personal information, but if you don’t, this may mean the psychological service may not be able to be provided to you.

Purpose of collecting and holding information

The information is gathered as part of the assessment, diagnosis and treatment of the client’s condition, and is seen only by the psychologist. The information is retained in order to document what happens during sessions, and enables the psychologist to provide a relevant and informed psychological service.

Access to client information

At any stage, you as a client are entitled to access to the information about you kept on file, unless the relevant legislation provides otherwise. The psychologist may discuss with you appropriate forms of access.


All personal information gathered by the psychologist during the provision of the psychological service will remain confidential. However, it is important to know there are exceptions in which all psychologists are mandated (by law) to break confidentiality. This can occur when:

  1. The information you have given to your psychologist is subpoenaed (officially requested) by a court of law
  2. Failure to disclose the information would place you or another person at serious risk of harm
  3. Your prior approval has been obtained to:
    1. provide a written report to another professional or agency, e.g. A GP or a lawyer; or
    2. discuss the material with another person, e.g. a parent or employer; or
    3. if disclosure is otherwise required or authorised by law.

Exchange of Client Information

There may be times where as part of the assessment and therapy process it may be helpful for your psychologist to liaise with other people or agencies that are relevant to your therapy goals (e.g. your GP, specialist, parent, WorkCover, etc).

Please note, that if you intend to claim rebates from Medicare or another organisation (such as WorkCover), and then your psychologist must provide summary reports to external agencies regarding your treatment progress. Under the Medicare scheme, these reports will normally be sent to your GP or psychiatrist.

In addition, administration staff may be involved in the handling of client information at times (i.e. when scheduling appointments, taking client information forms and measures).  One member of our administration team members is located in the Philippines and at times may manage the uploading of documents to client files.

Cancellation Policy

If for some reason you need to cancel or postpone your appointment, please provide at least 24 hours notice, otherwise you will be charged the FULL FEE for the session, with NO Medicare or Private Health Rebates applicable.