Client Consent | Caris Pepper

Ms Caris Roxanne Pepper, PACFA Reg.Certified Practising 29937
Masters in Therapeutic Arts Practice AthR (MTAP)

I need to collect information about you for the primary purpose of providing a quality service to you. In order to thoroughly assess, and provide therapy, I need to collect some personal information from you. This information will also be used for:

The administrative purpose of running the practice;
Billing either directly or through an agency;
Use within the practice if discussing or passing your case to another practitioner within the practice for your ongoing care;
Disclosure of information to your doctors, other health professionals to facilitate communication and best possible care for you

I do not disclose your personal information to other recipients.

I have a Privacy Policy that is available on my website www.carispepper.com

That policy provides guidelines on the collection, use, disclosure and security of your information. The Privacy Policy contains information on how you may request access to, and correction of, your personal information and how you may complain about a breach of your privacy and how we will deal with such a complaint.

To ensure the process of quality treatment provision, information about your assessment results and progress may be given to relevant other service providers, who are involved in your care.

Consent *

I have read the above information and understand the reasons for the collection of my personal information and the ways in which the information may be used and disclosed and I agree to that use and disclosure.
I understand that it is my choice as to what information I provide and that withholding or falsifying information might act against the best interests of my assessment/ supervision/therapy progress.
I am aware that I can access my personal information on request and if necessary, correct information that I believe to be inaccurate.
I understand that if, in exceptional circumstances, access is denied for legitimate purposes, that the reasons for this and possible remedies will be made available to me.
I have been provided with or have been given an opportunity to obtain a copy of the privacy policy.
I understand the general benefits and intentions of Arts Therapy and Energy Healing, including the contraindications of the treatment.
I understand that any therapy provided by Caris Pepper of ‘Caris Pepper Creative Therapies’ is not a substitute for medical treatment or medications, and that it is recommended that I concurrently work with my Primary Caregiver for any condition I may have.
I declare all the information I have given is true and informed my therapist of all known medical conditions, physical and mental, and I will keep my therapist updated on any changes.

Client consent and terms and conditions - By completing and signing this agreement form, you acknowledge you have read all terms, conditions and consent requirements outlined within.

Client Name *

First

Last

If Client is under 18yo: Guardian's Name

First

Last

Date *

The Relationship

The Client enters into sessions with the understanding that the Client is responsible for creating his or her own decisions and results. As requested, you may be given specific advice or suggestions; however, the Client agrees it is ultimately their own responsibility for making decisions to determine the best course of action.

Confidentiality

The content of these sessions will be kept confidential unless it has been identified that your safety or another’s safety is at risk.

Individuals under 18: I prioritize the confidentiality and safety of children and adolescents. Confidentiality is maintained throughout therapy sessions, with information shared only on a need-to-know basis. In cases where a child’s safety or well-being is at risk, I adhere to mandatory reporting requirements and will notify relevant authorities or individuals as necessary to ensure the child’s protection and welfare.

Notes of our sessions will be kept in a secure place. These notes will not be accessed by anyone else, except for the trainee art therapist, and will be kept for the purposes of continuity of care and as a learning tool for the therapist.

Your sessions may be recorded as a method of note taking (client information is protected under the 1988 privacy act). I am not permitted in any way to edited or modify these recordings without consent of Caris Pepper.

Your consent will be obtained if you wish for any of the content of your sessions to be communicated to another person/organisation.

Policy for Therapy Sessions with Minors

All sessions for individuals under 18 years of age require an initial session with the parent/guardian to discuss the child’s therapy needs and ensure a comprehensive understanding of the family context.

Indemnification

The Client shall indemnify and hold Caris Pepper harmless from any loss or liability arising from actions taken or situations created as a result of subsequent sessions.

Scheduling and Cancellation Policy

Payments for sessions are to be pre-paid. Payments can be made via bank transfer. Ongoing sessions can be paid for in session for the next booking.

Rescheduling a pre-paid session must occur within 7 days of the original booking.
You may only reschedule a pre-booked session once.
If you are unable to attend you rescheduled session, you will forfeit your payment.

24hrs notice is required to be eligible to reschedule your session or cancel without forfeiting your appointment fee. You must request a refund in writing to [email protected]. Please include your bank details with your request. A $50 administration fee applies.
**Please note that emergency cancellations are determined at the therapist’s
discretion.

CLIENT CONSENT FORM

Emergency contacts

CLIENT CONSENT FORM

Emergency contacts

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