Policy, Costs and Consent to Exchange Information
Please read every section, complete the details, sign, and return this form to Barbara before your first session (barbarab@playfulhealingtherapy.com). Please ask if anything is unclear. To save a copy, choose Print or save as PDF and select “Save as PDF” as the printer.
1. Informed consent for play therapy services
I/we, (parent/guardian name/s), have sought and consent to participate in the play therapy process for (child’s name), Date of Birth: , with therapist Barbara Beirao at Playful Healing Therapy.
I/we agree to be involved in the process and to regularly review the treatment, progress and process.
Barbara Beirao has received specialised Child-Centred Play Therapy training. Her practice is informed by the latest research in neuroscience, attachment in relation to trauma, and the impacts of trauma on mental health, childhood development and learning, and she attends regular supervision. Barbara works collaboratively with other allied health providers, education providers and community supports to give your family an integrative, informed and collaborative approach to meet your goals.
The therapist holds a current Working with Children Check and/or Police Clearance, is registered with a professional body (associated with her mental health qualification), and is an Associate Member of the Australian Play Therapists Association (APTA), membership number 20250880.
Should the therapist be away for a specified length of time, she may discuss a potential referral to another play therapist and will do everything possible to provide a transition period.
Services may end at your discretion, by mutual agreement, on completion of our work together, or on the therapist’s recommendation. If you decide to end services, we ask that you give adequate notice (at least 3 sessions) so that your child can be prepared for their time ending.
2. Confidentiality and privacy
I/we understand and agree that information about clients, including case records, is confidential and will only be released under the following conditions:
- a)For individual, peer and group supervision and professional development. To protect confidentiality, clients will be identified by first names only, or names may be changed to protect the identity of the child and family.
- b)Where a client has worked or is working with more than one therapist at Playful Healing Therapy, professional collaboration may occur to support the child/family.
- c)If the therapist determines that the client is a danger to themselves or to someone else.
- d)If the child or family discloses abuse, or the therapist has concerns about suspected child abuse.
- e)If there is a court order or other legal requirement to disclose information.
- f)Where I/we have given written consent, for example by signing the Consent to Release of Information in section 7.
Your therapist has a duty of care to you and your child. We will always endeavour to speak with you and discuss our concerns if confidentiality needs to be broken for any of the reasons above, unless doing so would put someone at risk.
In addition to our professional and ethical obligations, we handle your personal information in accordance with Federal and State privacy laws, including the Australian Privacy Principles in the Privacy Act 1988 (Cth) and the Health Privacy Principles in the Health Records Act 2001 (Vic). Records are kept until the child is 25 years of age and then securely destroyed. Our full Privacy Policy is available on this website.
More information: Health Records Act (Victoria) and Australian Privacy Principles (OAIC).
3. Fees and cancellation policy
I/we have discussed and understood the session fee and the cancellation policy with the therapist. Fees are discussed individually and reviewed from time to time, and I/we will be given notice of any change.
If you need to cancel or change an appointment, 48 hours’ notice is required to avoid being charged the full fee. If you do not attend a session without giving that notice, it will be treated as a no-show and the full session fee will be charged.
Payment is due at the end of each play therapy session. Alternatively, an invoice will be sent to you and must be paid within 7 days.
Other costs
I/we understand that I can ask Playful Healing Therapy to attend care team meetings, secondary consultations and to write reports, and that these are charged as a fee for service.
If Playful Healing Therapy is subpoenaed or asked to attend court, the party responsible will be invoiced for the hours allocated, up to the number of sessions per day, to cover clients’ sessions cancelled because of court proceedings. This must be paid before services continue after the court hearing. Transport, fuel and parking costs will also be charged.
4. Concerns, complaints and urgent help
If you have a concern about the service, please raise it with Barbara first so it can be resolved. You may also contact the Australian Association of Social Workers (AASW) or the Health Complaints Commissioner (Victoria) at hcc.vic.gov.au.
Playful Healing Therapy is not a crisis service. In an emergency call 000. For urgent support call Lifeline 13 11 14 or, for children and young people, Kids Helpline 1800 55 1800.
5. Exemption to joint parental/guardian consent
Complete this section only if only one parent/guardian is consenting. I request that my permission alone is accepted for my child to attend counselling. The reason is (please tick):
- I am the primary parent for my child.
- I do not know the location of the other parent and have taken all reasonable steps to locate them.
- The other parent has had no contact with the child/children for more than a year and there are no current Parenting Orders.
- I have a court order for sole parental responsibility (which is different from an order about who the child lives with).
- I believe that I or the child/children would be at risk of harm if the other parent were contacted about counselling.
- The other parent is deceased.
I understand that Barbara Beirao does not take responsibility for verifying the circumstances that support an exemption to joint parental/guardian consent. By signing, I confirm that I have read and understood these statements and that they are true.
6. For separation, divorce or custody cases
The counselling is designed to be therapeutic.
- a)No written report or verbal information will be provided to any person except as required by law. Barbara Beirao respects the confidential nature of counselling and will keep information confidential to the extent permitted by law and as needed to carry out her duty of care.
- b)Only general information may be provided to an Independent Children’s Lawyer appointed by the Court, in line with the Federal Circuit and Family Court of Australia’s guidelines. No reports will be provided for family law matters.
- c)Your child’s and family’s information will be held in the highest confidence; however, it may be discussed as part of professional supervision.
I/we agree not to ask the therapist for a report or to attend court, and not to subpoena the therapist or her records, for family law proceedings. I/we understand that a court may still require disclosure by law. Please initial:
Signature of parent/guardian initiating referral
Name:
Relationship to child:
Signature:
Date:
Name:
Relationship to child:
Signature:
Date:
Second parent/guardian, if applicable, uses the right-hand column.
7. Consent to release of information
Complete this section if you would like Barbara to share information with, or receive information from, other professionals or services involved with your child (for example a school, GP, paediatrician, psychologist or NDIS provider).
| Child/client name | |
|---|---|
| Date of birth | |
| Current address | |
| Parent/caregiver name | |
| Relationship to client |
By signing this form, I authorise Barbara Beirao at Playful Healing Therapy to share verbal and written information about the care provided to (child/client name) with the following professionals/parties:
| Name and role of professional | Agency / organisation | Phone or email |
|---|---|---|
| 1. | ||
| 2. | ||
| 3. | ||
| 4. | ||
| 5. | ||
| 6. |
Information that may be shared (please tick all that apply):
- Verbal discussion about my child’s progress and needs
- Written reports, summaries or letters
- Clinically relevant documentation and assessment data
I consent to Barbara Beirao receiving and providing copies of any clinically relevant documentation, reports and/or assessment data to and from the professionals listed above. Information will only be shared for the purpose of supporting my child’s care.
I understand that: this consent is valid for 12 months from the date signed unless I withdraw it earlier; I can withdraw or change this consent at any time by telling Barbara in writing (withdrawal does not affect information already shared); I am not required to give this consent in order to receive services; and I confirm that I have legal authority to give consent for this child.
Printed name (parent/caregiver):
Signature:
Date: