The Talk Shop Client Details and Consent Form – In-school counselling sessions"*" indicates required fieldsYour school has organised for your child to participate in counselling sessions at their school. This intake and consent form covers in-school counselling sessions.(Any counselling directly and independently with The Talk Shop will need completion of our standard consent form).Psychological Service Personal InformationAs part of providing a psychological service to you, we will need to collect and record personal information from you that is relevant to your child’s current situation. This information will be a necessary part of the counselling sessions that are conducted. You may view and/or have a copy of the material recorded in your file upon request, subject to the exceptions in National Privacy Principle 6.ConfidentialityAll personal information gathered by the psychologist during the provision of the psychological service will remain confidential and secure within the organisation except when: It is subpoenaed by a court, or Failure to disclose the information would place you or another person at risk; or Your prior approval has been obtained to:– provide a written report to another previously uninvolved professional or agency.e.g. a GP or a lawyer; or– discuss the material with another person. e.g. a parent or wellbeing leaderFor counselling sessions held at the school, a summary report will be sent to the School Wellbeing Leader, who will forward it to you. This report will summarise the focus/goals of the session and strategies to practice in the classroom or at home.Whilst the school and The Talk Shop may use email for general communication, we do not recommend you send confidential information to your psychologist via email, as email is not secure and your privacy cannot be guaranteed.Limitations of serviceYou acknowledge that we are not an emergency service, are not always available at short notice or outside our regular practice hours, and we may not be able to respond to telephone calls or emails requesting urgent assistance. Ask your psychologist if you wish to be provided with the details of other services who can provide these services.School name*Child's detailsFirst Name* First Middle Name Middle Last Name* Last Preferred Name First Date of Birth* YYYY dash MM dash DDGender* Female Male OtherResidential Address (must NOT be PO Box, etc)* Street Address Suburb State Postcode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Parent/Guardian detailsParent/Guardian's Name* Parent/Guardian’s first name Parent/Guardian’s last name Relationship to ChildEmail* Mobile Phone*Child's Medical PractitionerName:PhoneDate of last contact YYYY dash MM dash DDChild's previous Counsellor/Therapist (if any)NamePhoneDate of last contact YYYY dash MM dash DDIs there anything we should or need to know about yourself, your child or situation that might affect your child's safety or the safety of staff of the school or The Talk Shop?*Are there any unresolved legal matters?*NoYesSuch as divorce and custody mattersWhat is your understanding of the school including your child in the counselling program?*I have read and understood the above Consent Form. I agree to these conditions for the psychological service provided at the school to the child under my care.Signature*Please put the answer to this equation in the boxOn clicking Submit, we will send you a confirmation email, with information on getting the necessary paperwork to us.
