Boronia Informed Consent Form | Mental Health Care

CLIENT INFORMED CONSENT- BORONIA

RETURN TO FACE TO-FACE CONSULTATIONS DURING COVID-19

Resuming face to face consults is not without its risks, and although we will be taking precautions, in any public setting it is not possible to eliminate the risk of virus transmission completely. We advise you to consider your personal circumstances when deciding whether or not to attend the clinic for sessions. You now have more choices for psychology available to you, and along with re-opening Face to Face appointments, please be aware that Telehealth (video conference or phone consults) will continue to be available until further notice.

This document contains important information about the decision (yours & your practitioners) to resume face to face consultations at the clinic, and explains the precautions being put in place by the clinic to reduce risk.

Please read this carefully and if you have any questions at all our reception staff are happy to assist you.

Please note: By signing this document, you are acknowledging that you understand and agree to abide by the rules of attendance, and this signed form will be an official agreement between you and your practitioner. You also acknowledge that at any time, due to circumstances out of our control, your practitioner may without warning need to return to offering Telehealth services only.

If you or your practitioner are unwell

At Fernhills Clinic we are committed to keeping you, our staff and all our families safe from the spread of Coronavirus. For this reason, if you turn up for a scheduled appointment and your practitioner or our reception staff believe that you are displaying symptoms of ill health, or believe you have been exposed to the virus, we will require you to leave the clinic immediately. We can follow up with service by telehealth if necessary.
If your practitioner (or any staff) are identified as a close contact or test positive for the coronavirus, we will notify you so that you can take appropriate precautions.

RULES OF ATTENDANCE- Your responsibility to minimize your exposure

To obtain service in person at the clinic, you agree to take certain precautions which will help to keep everyone safer from exposure, and possible sickness. If you do not adhere to these safeguards, it will result in a return to a telehealth arrangement.

Please tick each item below to indicate that you understand and agree to the following:

You will only attend the clinic for your appointment if you are symptom free (no temperature, sore throat or any other cold or cough symptoms). You have not been advised to quarantine, or isolate, and you are not awaiting your covid test results.

You will not attend the clinic if you have visited a public exposure site within the specified times listed on coronavirus.vic.gov.au.

Upon arrival, please check your temperature at the main entrance & proceed to the reception area within Doctors Care Clinic to check in. A fitted mask must be worn by any persons entering the clinic building.

Please sign in using QR code to register your attendance at Melbourne Eastern Health, or ask reception for alternative sign in method.

Once you have checked in with reception, please proceed up to the Fernhills Clinic suite (2 nd floor) and wait in the waiting area. We ask that you sign in using the QR code provided in our waiting area, which is specifically for Fernhills Clinic attendees, and will enable us to contact you promptly in the event that we become an exposure site.

You will be on time for your scheduled appointment. Due to social-distancing precautions we are keeping to a minimum number of people at the clinic at any one time. This means that practitioners will adhere to scheduled 50 minute session times.

We are ensuring good hygiene practices are rigorously followed by all practitioners, staff & clients. We require anyone entering our rooms to either wash their hands, or use the alcohol- based hand sanitizer upon entering.

You will adhere to the safe distancing precautions we have set up in the waiting & therapy rooms.

You will keep a safe distance of 1.5 metres from your practitioner and any other staff whilst in the building (this also includes other clients) and there will be no physical contact such as shaking hands.

If you are bringing your child to an appointment, or you are responsible for another person attending the clinic, you will make sure that these sanitation and distancing protocols are followed by all in attendance.

No siblings/additional people other than the client and client-parent are to attend the clinic unless agreed by pre-arrangement with practitioner.

If you have a job that exposes you to other people who are infected, you will immediately let your psychologist know.

If you or a resident of your home tests positive for Covid-19, you will immediately let us know, and we will then resume treatment via telehealth.

Fernhills Clinic is following the guidelines set out by the Department of Health and the Government’s “National Covid-19 Safework principles”. If their advice or any other advice from the local or state government requires us to change or add to our procedures, we will keep you notified.

Fernhills Clinic- Our Commitment to Minimize Exposure

Our clinic has taken steps to reduce the risk of spreading the virus within our clinic and we have posted our efforts on our website and in the clinic. Please let us know if you have any questions about these precautions.

Confidentiality

If you have tested positive for the coronavirus, we may be required to notify local health authorities that you have been in the clinic. If we have to report this, we will only provide the minimum information necessary for their data collection and all other client information relating to the reason you are attending the clinic is kept confidential.

By signing this form, you are agreeing that we may do so without an additional signed release

Informed Consent- this agreement is in addition to the contract that you signed at the commencement of your therapy at Fernhills Clinic, and your signature confirms that you agree to all the terms and conditions set out in this document.

CLIENT'S NAME

DATE

CLIENT SIGNATURE

PSYCHOLOGIST SIGNATURE

DATE

FOR PRACTITIONER USE ONLY
CLIENT COVID VACCINATION CERTIFICATE CITED: Yes
No

DATE VALID FROM:

PSYCHOLOGIST SIGNATURE:

Contact Us

FERNTREE GULLY

347 Scoresby Road,
Ferntree Gully VIC 3156

BORONIA
(Melbourne Eastern Healthcare)

157 Scoresby Road,
Boronia VIC 3155

Clinic Hours

Monday – Friday: 9am – 6pm

Saturday: 9am – 1pm

Sunday: Closed

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Client Informed Consent

This form only needs to be completed if you are attending face to face sessions at the clinic during Covid-19.

Please select clinic location for your sessions

FTG Clinic Boronia Clinic

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