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INTAKE FORM & CONSENT TO SERVICE

Consent to service agreement form for assessment services

Please ensure you have carefully read through the information document relating to the assessment service required and have directed any queries or concerns to Nicola PRIOR to completing this consent document.

Growing Minds Clinical Psychology
psychassessments@outlook.com
0480 360 080

1.YOUR CHILD'S PERSONAL INFORMATION(Required.)
2.Name of parent/legal guardian completing this form:(Required.)
3.PARENT/LEGAL GUARDIAN INFORMATION (PRIMARY CONTACT)(Required.)
4.SECONDARY PARENT/LEGAL GUARDIAN INFORMATION
5.I confirm that I am the parent and/or legal guardian of the child(Required.)
6.Do both parents consent to this service (if applicable)?(Required.)
7.ASSESSMENT DETAILS
Please select which assessment service you are booking(Required.)
8.I confirm that I have read through the full information document pertaining to the selected assessment above and fully agree to all terms and conditions stated in the document, including fees and use of recordings for clinical note-taking (compliant with AHPRA and HIPAA standards).(Required.)
9.I agree to Nicola Albrecht/Growing Minds Clinical Psychology contacting the following, to request and share information relevant to this assessment
10.I agree to Nicola Albrecht/Growing Minds Clinical Psychology contacting the other following professionals involved in the care of my child (please complete if/as applicable):
11.Are there any Family Court or Children's Court orders that affect this child?
12.Thank you for completing this document.
Please feel free to provide any comments or additional information here, if applicable
13.Where did you hear about our service?
14.By clicking the ACCEPT button below, you are agreeing to all terms and conditions on the relevant assessment information document and your response will be accepted as an online/digital signature.(Required.)