Telehealth Client Consent Form

This form is to be used in addition to our standard consent form.

Background and Services – Telehealth

Mind Potential Psychology (MPP) uses Cliniko to deliver our Telehealth services. Cliniko is a private company that is separate and outside of MPP. You can obtain information about Cliniko and its privacy policy here:


As is our usual process (i.e., outlined in our standard consent form) we will treat your information with respect and in confidence. We will not record the sessions nor share material from the Cliniko sessions without your consent (unless due to reasons outlined in confidentiality). We also ask that you do not record the sessions. You will receive a link to join your video call via email in your usual Appointment Reminder emails. You are not required to download or install an app to conduct Cliniko sessions.

Telehealth services utilise interactive cloud based systems that involve sharing of audio, video or other data communication online (outside of our practice).

Our practitioners make the commitment to undertake telehealth consultations in a private setting. We recommend that you also find a private setting. It is important that steps are made by you to protect your information.


Please minimize distractions during your session. This may include not playing games (unless with your psychologist), sending messages or doing other activities. Treat this like your usual face-to-face sessions and your psychologist/counsellor will do the same.

Safety & Confidentiality

In the event that your psychologist/counsellor is concerned about your safety or the safety of others, the usual limitations to confidentiality (as outlined in our standard consent form) apply.

Data Transfer & Usage

Please check that you have enough data to undertake the conference calls. MPP will not cover the cost of the data usage for these calls. MPP can also not take responsibility for any disruptions to your call due to poor internet connection. We will make all reasonable efforts to make sure we use reliable internet connections when undertaking our sessions, however, as the internet can be unreliable we are unable to promise uninterrupted sessions.

Cancellations or Non Arrivals

Our usual cancellation policy applies. We require 24 hours notice to cancel/reschedule your session to avoid being charged the FULL fee.

By accepting and signing the method of Telehealth services:

☐ I have read, understood and I agree to the above information.